Provider Demographics
NPI:1740310259
Name:LEAKE, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
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 1:819 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4332
Mailing Address - Country:US
Mailing Address - Phone:704-340-8290
Mailing Address - Fax:
Practice Address - Street 1:201 E GROVER ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3917
Practice Address - Country:US
Practice Address - Phone:980-487-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC127380207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910332Medicaid