Provider Demographics
NPI:1669140406
Name:LEAK, TALLIS (MD,DO)
Entity type:Individual
Prefix:
First Name:TALLIS
Middle Name:
Last Name:LEAK
Suffix:
Gender:M
Credentials:MD,DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 TRAWICK RD STE 4
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-3770
Mailing Address - Country:US
Mailing Address - Phone:919-332-9235
Mailing Address - Fax:
Practice Address - Street 1:2940 TRAWICK RD STE 4
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-3770
Practice Address - Country:US
Practice Address - Phone:919-332-9235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-04
Last Update Date:2021-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver