Provider Demographics
NPI:1780630392
Name:LEATHAM, KINNARD J (MD)
Entity Type:Individual
Prefix:
First Name:KINNARD
Middle Name:J
Last Name:LEATHAM
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 1:545 N RIVER ST
Mailing Address - Street 2:#130
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-2600
Mailing Address - Country:US
Mailing Address - Phone:570-552-2760
Mailing Address - Fax:570-552-2765
Practice Address - Street 1:545 N RIVER ST
Practice Address - Street 2:#130
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-2600
Practice Address - Country:US
Practice Address - Phone:570-552-2760
Practice Address - Fax:570-552-2765
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA079207208600000X
NJMA0769332086S0102X
PAMD418397208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0039381Medicaid
NJ1087117OtherAETNA
PA0018088940006Medicaid
NJ2404983000OtherAMERIHEALTH
NJP3624813OtherOXFORD
086606Medicare ID - Type Unspecified
NJP3624813OtherOXFORD
PA0018088940006Medicaid