Provider Demographics
NPI:1629043773
Name:LEAHY, MARK T (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:LEAHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2384
Mailing Address - Country:US
Mailing Address - Phone:402-721-3133
Mailing Address - Fax:402-941-7017
Practice Address - Street 1:700 E 29TH ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2384
Practice Address - Country:US
Practice Address - Phone:402-721-3133
Practice Address - Fax:402-941-7017
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19033207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47053664516Medicaid
NEF58019Medicare UPIN
NE47053664516Medicaid