Provider Demographics
NPI:1831197524
Name:LEATH, MICHAEL CARTER (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CARTER
Last Name:LEATH
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:PO BOX 2506
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606
Mailing Address - Country:US
Mailing Address - Phone:903-235-4232
Mailing Address - Fax:903-663-0551
Practice Address - Street 1:7470 STATE HWY 154
Practice Address - Street 2:OAK HAVEN RECOVERY CENTER
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670
Practice Address - Country:US
Practice Address - Phone:903-938-5149
Practice Address - Fax:903-753-9141
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2672207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0004357854OtherAETNA
TX131170604Medicaid
TX0043GGOtherBLUE CROSS
TX110219847OtherRAILROAD MEDICARE
TX110219847OtherRAILROAD MEDICARE
TX131170604Medicaid