Provider Demographics
NPI:1861490732
Name:LEONARD, JACK J (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:J
Last Name:LEONARD
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 1:122 W 7TH AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2349
Mailing Address - Country:US
Mailing Address - Phone:509-456-0262
Mailing Address - Fax:509-462-5059
Practice Address - Street 1:122 W 7TH AVE
Practice Address - Street 2:STE 110
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2349
Practice Address - Country:US
Practice Address - Phone:509-456-0262
Practice Address - Fax:509-462-5059
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018141208G00000X
IDM-8957208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004173400Medicaid
ID11107621OtherMEDICARE PTAN
WAG8878300OtherMEDICARE PTAN
WAG8871041OtherMEDICARE PTAN
WA1599901Medicaid
ID004173400Medicaid
ID11107621OtherMEDICARE PTAN
WA1599901Medicaid