Provider Demographics
NPI:1104814599
Name:LEADINGHAM, JAMES C (OD, PSC)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:C
Last Name:LEADINGHAM
Suffix:
Gender:M
Credentials:OD, PSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 VINSON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230
Mailing Address - Country:US
Mailing Address - Phone:606-638-4731
Mailing Address - Fax:606-638-3523
Practice Address - Street 1:112 VINSON BLVD
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1155
Practice Address - Country:US
Practice Address - Phone:606-638-4731
Practice Address - Fax:606-638-3523
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0731DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77007318Medicaid
KY000000305678OtherBCBS
WV0149556000Medicaid
KY1432032OtherUNITED MINE WORKERS H&R
KYP00134006OtherRAILROAD MEDICARE
KY610980551OtherTAX ID
KYT54637Medicare UPIN
WV0149556000Medicaid
KY000000305678OtherBCBS