Provider Demographics
NPI:1639495492
Name:ALLEN, JOHN LEATHERBURY (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEATHERBURY
Last Name:ALLEN
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 1:3853 BYRNWYCK PL NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1658
Mailing Address - Country:US
Mailing Address - Phone:251-533-8739
Mailing Address - Fax:
Practice Address - Street 1:3853 BYRNWYCK PL NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-1658
Practice Address - Country:US
Practice Address - Phone:251-533-8739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GARESIDENT4405207R00000X
GA74229207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program