Provider Demographics
NPI:1932110855
Name:LEICHTMAN, LAWRENCE GENE (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:GENE
Last Name:LEICHTMAN
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:PO BOX 4548
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-0548
Mailing Address - Country:US
Mailing Address - Phone:757-425-1969
Mailing Address - Fax:957-425-1822
Practice Address - Street 1:1405 E KILN CREEK PARKWAY
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-9700
Practice Address - Country:US
Practice Address - Phone:757-425-1969
Practice Address - Fax:757-425-1822
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042384207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890548POtherMEDICAID
VA6027571Medicaid
VA6027571Medicaid