Provider Demographics
NPI:1891793055
Name:LECLAIRE, JERRY E (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:E
Last Name:LECLAIRE
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 1:427 S BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2509
Mailing Address - Country:US
Mailing Address - Phone:509-456-0107
Mailing Address - Fax:509-747-2635
Practice Address - Street 1:427 S BERNARD ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2509
Practice Address - Country:US
Practice Address - Phone:509-456-0107
Practice Address - Fax:509-747-2635
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022725207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA32912OtherLABOR AND INDUSTRIES
WAE48924OtherASURIS(REGENCE NW HEALTH)
IDK3515OtherBLUE CROSS OF ID
WA8100927Medicaid
WAWA0690OtherNORTHWEST BENEFIT NETWORK
WA565OtherGROUP HEALTH
WAA017OtherTRICARE
ID000010003058OtherASURIS(REGENCE BS OF ID)
WA8100927Medicaid