Provider Demographics
NPI:1841254323
Name:LEICHT, MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:LEICHT
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 820933
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-926-9010
Mailing Address - Fax:215-226-8285
Practice Address - Street 1:9331 OLD BUSTLETON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4634
Practice Address - Country:US
Practice Address - Phone:215-671-0653
Practice Address - Fax:215-671-0970
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024528E207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000777434Medicaid
PA597586OtherMEDICARE GROUP
PA597586OtherMEDICARE GROUP
PA195910POQMedicare ID - Type Unspecified
PA000777434Medicaid