Provider Demographics
NPI:1255453320
Name:LEESCH, WOLFGANG (MD)
Entity type:Individual
Prefix:DR
First Name:WOLFGANG
Middle Name:
Last Name:LEESCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12200 WARWICK BLVD
Practice Address - Street 2:SUITE 480
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601
Practice Address - Country:US
Practice Address - Phone:757-534-5200
Practice Address - Fax:757-534-5830
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012506692084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1255453320Medicaid
VAVV4407AMedicare PIN
VAP01028360Medicare PIN