Provider Demographics
NPI:1710971635
Name:LEEK, LISA L (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:LEEK
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:PO BOX 22505
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2505
Mailing Address - Country:US
Mailing Address - Phone:866-321-8433
Mailing Address - Fax:
Practice Address - Street 1:5001 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1308
Practice Address - Country:US
Practice Address - Phone:601-268-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15897207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119543Medicaid
G21150Medicare UPIN