Provider Demographics
NPI:1790768216
Name:LEESS, FRED R (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:R
Last Name:LEESS
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 1:140 COLEMANS XING
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-7080
Mailing Address - Country:US
Mailing Address - Phone:937-578-4300
Mailing Address - Fax:937-578-4311
Practice Address - Street 1:140 COLEMANS XING
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-7080
Practice Address - Country:US
Practice Address - Phone:937-578-4300
Practice Address - Fax:937-578-4311
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083442L207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2450771Medicaid
OH2450771Medicaid
E41292Medicare UPIN