Provider Demographics
NPI:1780698605
Name:LEATHERWOOD, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LEATHERWOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4351 E LOHMAN AVE STE 405
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8261
Mailing Address - Country:US
Mailing Address - Phone:575-522-0091
Mailing Address - Fax:575-522-4984
Practice Address - Street 1:4351 E LOHMAN AVE STE 405
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8261
Practice Address - Country:US
Practice Address - Phone:575-522-0091
Practice Address - Fax:575-522-4984
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine