Provider Demographics
NPI:1750342986
Name:LEATHERWOOD, LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:LYNN
Middle Name:
Last Name:LEATHERWOOD
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 1:15286 COMMUNITY RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3509
Mailing Address - Country:US
Mailing Address - Phone:228-832-5151
Mailing Address - Fax:228-832-6320
Practice Address - Street 1:15286 COMMUNITY RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3509
Practice Address - Country:US
Practice Address - Phone:228-832-5151
Practice Address - Fax:228-832-6320
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10834207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS110098184OtherRAILROAD MEDICARE
MS00114491Medicaid
MSD00903Medicare UPIN
MS110000697Medicare PIN