Provider Demographics
NPI:1790798023
Name:LEADBETTER, ALLEN W
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:W
Last Name:LEADBETTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 WELLS ST
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-2924
Mailing Address - Country:US
Mailing Address - Phone:401-596-0174
Mailing Address - Fax:401-596-2266
Practice Address - Street 1:46 WELLS ST
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2924
Practice Address - Country:US
Practice Address - Phone:401-596-0174
Practice Address - Fax:401-596-2266
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIL5016208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI225399OtherBLUE SHIELD
RI9002352Medicaid
CT010005016RT101OtherBLUE SHIELD
CT010005016RT101OtherBLUE SHIELD