Provider Demographics
NPI:1861483729
Name:LEINICKE, JEFFREY A (MD)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:A
Last Name:LEINICKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1675 LEAHY ST
Mailing Address - Street 2:STE 324B
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5500
Mailing Address - Country:US
Mailing Address - Phone:231-725-5075
Mailing Address - Fax:231-722-1827
Practice Address - Street 1:1675 LEAHY ST
Practice Address - Street 2:STE 324B
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5500
Practice Address - Country:US
Practice Address - Phone:231-725-5075
Practice Address - Fax:231-722-1827
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301041596207RG0100X
WAMD60095455207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2803023Medicaid
MI0F17616001OtherMEDICARE ID
MIB43546Medicare UPIN
MI2803023Medicaid