Provider Demographics
NPI:1639375140
Name:LEACOCK, BENJAMIN WILLIAM
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WILLIAM
Last Name:LEACOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:WILLIAM
Other - Last Name:LEACOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 912215
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2215
Mailing Address - Country:US
Mailing Address - Phone:303-306-7101
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:200 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1154
Practice Address - Country:US
Practice Address - Phone:618-664-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0056078207P00000X
IN01081797A207P00000X
MO2010003231207P00000X
NC141051390200000X
IL036148647207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program