Provider Demographics
NPI:1558410191
Name:LEESON, THOMAS A (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:LEESON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-746-0206
Mailing Address - Fax:856-746-0207
Practice Address - Street 1:141 BRIDGETON PIKE UNIT B
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-2615
Practice Address - Country:US
Practice Address - Phone:856-746-0206
Practice Address - Fax:856-746-0207
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272208207P00000X
NH15352207Q00000X
NJ25MB11150900207Q00000X
NHLT 3042207Q00000X
PAOS016477207Q00000X
ME2097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30229007Medicaid
ME432682399Medicaid
VT1019471Medicaid
VT1019471Medicaid
ME432682399Medicaid
NH001425502Medicare PIN