Provider Demographics
NPI:1821100066
Name:LEATHERWOOD, DANNY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:DANNY
Middle Name:LYNN
Last Name:LEATHERWOOD
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:714 N SENATE AVE
Practice Address - Street 2:STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3763
Practice Address - Country:US
Practice Address - Phone:317-715-6381
Practice Address - Fax:317-472-4566
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ355252085R0202X
IN010577702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
620864298OtherTRICARE
TN1506086Medicaid
IN201010540Medicaid
TN4141784OtherBCBS PROVIDER NUMBER
INP00860880OtherRAILROAD MEDICARE
3001708Medicare PIN
620864298OtherTRICARE