Provider Demographics
NPI:1700825957
Name:LEATH, SUSAN JONES (MD)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JONES
Last Name:LEATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 CARPENTER LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-3406
Mailing Address - Country:US
Mailing Address - Phone:215-848-6880
Mailing Address - Fax:215-848-3333
Practice Address - Street 1:760 CARPENTER LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-3406
Practice Address - Country:US
Practice Address - Phone:215-848-6880
Practice Address - Fax:215-848-3333
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039739L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1276149Medicaid
PA1276149Medicaid
PA039747Medicare ID - Type Unspecified