Provider Demographics
NPI:1659307361
Name:LEITHEISER, GREGORY J (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:J
Last Name:LEITHEISER
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 1:1475 WEBB ST
Mailing Address - Street 2:PO BOX 127
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829
Mailing Address - Country:US
Mailing Address - Phone:715-822-2231
Mailing Address - Fax:715-822-2023
Practice Address - Street 1:1475 WEBB ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829
Practice Address - Country:US
Practice Address - Phone:715-822-2231
Practice Address - Fax:715-822-2023
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31547600Medicaid
050020006Medicare ID - Type Unspecified
WI31547600Medicaid