Provider Demographics
NPI:1962468587
Name:LEAK, ROBERT S (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:LEAK
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 1:210 VILLAGE CENTER BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6683
Mailing Address - Country:US
Mailing Address - Phone:843-236-3222
Mailing Address - Fax:843-236-3005
Practice Address - Street 1:210 VILLAGE CENTER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-6683
Practice Address - Country:US
Practice Address - Phone:843-236-3222
Practice Address - Fax:843-236-3005
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23258207XS0106X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8906243Medicaid
SCT74602Medicaid
NC8906243Medicaid