Provider Demographics
NPI:1790947208
Name:LECKY, DANIELLE J (MD)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:J
Last Name:LECKY
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 1:11315 PEMBROOKE SQ
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4806
Mailing Address - Country:US
Mailing Address - Phone:301-843-6996
Mailing Address - Fax:301-843-6996
Practice Address - Street 1:11315 PEMBROOKE SQ
Practice Address - Street 2:SUITE 110
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4806
Practice Address - Country:US
Practice Address - Phone:301-843-6996
Practice Address - Fax:301-843-6996
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00760342080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD321900300Medicaid