Provider Demographics
NPI:1831486117
Name:LEIKNESS, MARY HALLMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:HALLMAN
Last Name:LEIKNESS
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 1:358 S. OXFORD STREET
Mailing Address - Street 2:POB 207
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-0000
Mailing Address - Country:US
Mailing Address - Phone:920-787-7395
Mailing Address - Fax:
Practice Address - Street 1:358 S. OXFORD STREET
Practice Address - Street 2:POB 207
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-0000
Practice Address - Country:US
Practice Address - Phone:920-787-7395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20839-020208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology