Provider Demographics
NPI:1295774438
Name:LEROY, JOHN W
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:LEROY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7920 MOUNT HARMONY LN
Mailing Address - Street 2:
Mailing Address - City:OWINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20736-3404
Mailing Address - Country:US
Mailing Address - Phone:410-257-0439
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4017
Practice Address - Country:US
Practice Address - Phone:301-855-1012
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002317363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP38118Medicare UPIN
MD584L-B627Medicare ID - Type Unspecified