Provider Demographics
NPI:1952448136
Name:LECLOUX, DAVID ROLAND (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROLAND
Last Name:LECLOUX
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:W 8976 PHEASANT DRIVE
Mailing Address - Street 2:
Mailing Address - City:CRIVITZ
Mailing Address - State:WI
Mailing Address - Zip Code:54114-9282
Mailing Address - Country:US
Mailing Address - Phone:715-854-3554
Mailing Address - Fax:
Practice Address - Street 1:W 8976 PHEASANT DRIVE
Practice Address - Street 2:
Practice Address - City:CRIVITZ
Practice Address - State:WI
Practice Address - Zip Code:54114-9282
Practice Address - Country:US
Practice Address - Phone:715-854-3554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18518-020207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB54497Medicare UPIN