Provider Demographics
NPI:1013902907
Name:LEICHT, STUART S (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:S
Last Name:LEICHT
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 1:2898 BOONES CREEK RD STE 105
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4976
Mailing Address - Country:US
Mailing Address - Phone:423-262-0112
Mailing Address - Fax:423-433-6060
Practice Address - Street 1:2898 BOONES CREEK RD STE 105
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4976
Practice Address - Country:US
Practice Address - Phone:423-262-0112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD17098207N00000X, 207NP0225X, 207NS0135X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3021885Medicare ID - Type Unspecified