Provider Demographics
NPI:1922066356
Name:LEITKAM, BRUCE C (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:C
Last Name:LEITKAM
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 1:490 W BROAD ST
Mailing Address - Street 2:PO BOX 605
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-8768
Mailing Address - Country:US
Mailing Address - Phone:810-735-1231
Mailing Address - Fax:810-735-1092
Practice Address - Street 1:490 W BROAD ST
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-8768
Practice Address - Country:US
Practice Address - Phone:810-735-1231
Practice Address - Fax:810-735-1092
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006591208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4075401OtherAETNA
MI1552457Medicaid
MIM028466OtherTRICARE
MI015251061OtherBLUECROSS BLUE SHIELD OF
MI5253934Medicare ID - Type Unspecified
MI4075401OtherAETNA