Provider Demographics
NPI:1659052561
Name:LEACH, GARY CHRISTOPHER (IDMT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:CHRISTOPHER
Last Name:LEACH
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 78 BOX 912
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96326-0010
Mailing Address - Country:US
Mailing Address - Phone:315-225-7740
Mailing Address - Fax:
Practice Address - Street 1:374TH MEDICAL GROUP, UNIT 5071
Practice Address - Street 2:YOKOTA AIR BASE
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96328-5071
Practice Address - Country:US
Practice Address - Phone:315-225-7740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians