Provider Demographics
NPI:1790853976
Name:LEETZ, KENNETH LAURENCE (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LAURENCE
Last Name:LEETZ
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 1:80 PEACHTREE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-3156
Mailing Address - Country:US
Mailing Address - Phone:828-274-8035
Mailing Address - Fax:828-274-6906
Practice Address - Street 1:80 PEACHTREE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-3156
Practice Address - Country:US
Practice Address - Phone:828-274-8035
Practice Address - Fax:828-274-6906
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97-006332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2239031Medicare ID - Type UnspecifiedDR LEETZ
NCB30550Medicare UPIN