Provider Demographics
NPI:1891762514
Name:LEADINGHAM, JOHN C (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:LEADINGHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1069
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1069
Mailing Address - Country:US
Mailing Address - Phone:606-325-9659
Mailing Address - Fax:606-329-1258
Practice Address - Street 1:1330 CARTER AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7544
Practice Address - Country:US
Practice Address - Phone:606-325-9659
Practice Address - Fax:606-329-1258
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1659-DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYV08326Medicare UPIN
KY0785902Medicare ID - Type Unspecified