Provider Demographics
NPI:1356334825
Name:LEAKE, JAMES EDGAR (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EDGAR
Last Name:LEAKE
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 1:672 BEAUREGARD DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-5509
Mailing Address - Country:US
Mailing Address - Phone:770-422-3386
Mailing Address - Fax:770-422-3386
Practice Address - Street 1:672 BEAUREGARD DR SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-5509
Practice Address - Country:US
Practice Address - Phone:770-422-3386
Practice Address - Fax:770-422-3386
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2019-01-02
Deactivation Date:2018-11-16
Deactivation Code:
Reactivation Date:2018-12-10
Provider Licenses
StateLicense IDTaxonomies
GA0261442086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA24BCBKNMedicare ID - Type Unspecified
D40422Medicare UPIN