Provider Demographics
NPI:1700989233
Name:LEESTMA, ERIC J
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:LEESTMA
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:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-0850
Mailing Address - Country:US
Mailing Address - Phone:219-987-7750
Mailing Address - Fax:219-987-5750
Practice Address - Street 1:519 N HALLECK
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310
Practice Address - Country:US
Practice Address - Phone:219-987-7750
Practice Address - Fax:219-987-5750
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000641A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100209310AMedicaid
IN36655OtherINDIANA HEALTH NETWORK
IN000000084931OtherANTHEM BCBS
IN36655OtherINDIANA HEALTH NETWORK
D95508Medicare UPIN
080088241Medicare PIN