Provider Demographics
NPI:1295754562
Name:LEITNER, THOMAS C (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:C
Last Name:LEITNER
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 1:501 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-5614
Mailing Address - Country:US
Mailing Address - Phone:704-283-9068
Mailing Address - Fax:704-283-4705
Practice Address - Street 1:1428 ELLEN ST
Practice Address - Street 2:SUITE A
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5173
Practice Address - Country:US
Practice Address - Phone:704-289-4361
Practice Address - Fax:704-283-4705
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30830174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC85112Medicare UPIN