Provider Demographics
NPI:1679682710
Name:LEICKLY, FREDERICK E (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:E
Last Name:LEICKLY
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:DEPT. 453 PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:2665 FOX POINTE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-3222
Practice Address - Country:US
Practice Address - Phone:812-378-3131
Practice Address - Fax:812-379-9251
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042436A207K00000X
IN010424362080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100379150Medicaid
ININ1125015OtherMEDICARE PTAN
145590UUMedicare ID - Type Unspecified