Provider Demographics
NPI:1023279197
Name:LEENAY, MARK (MD, MS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:LEENAY
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6940 338TH LN NW
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-5007
Mailing Address - Country:US
Mailing Address - Phone:763-389-9417
Mailing Address - Fax:
Practice Address - Street 1:6940 338TH LN NW
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-5007
Practice Address - Country:US
Practice Address - Phone:763-389-9417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-22
Last Update Date:2008-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33571207Q00000X, 207QG0300X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN40496Medicare PIN
MNE22107Medicare UPIN