Provider Demographics
NPI:1861461378
Name:LECKIE, CHARLES (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:LECKIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 E PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5599
Mailing Address - Country:US
Mailing Address - Phone:662-377-4685
Mailing Address - Fax:662-377-2755
Practice Address - Street 1:903 MISSISSIPPI DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-0928
Practice Address - Country:US
Practice Address - Phone:662-377-4652
Practice Address - Fax:662-377-7925
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125648Medicaid
MS080003951Medicare ID - Type Unspecified
MSH52918Medicare UPIN