Organization
LIESEL E.A. LEEDY MD PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LIESEL E.A. LEEDY MD (PRESIDENT)
(936) 462-7844
Entity
Organization
Contact information
Practice address
1204 N MOUND ST, NACOGDOCHES, TX 75961-4027
(936) 564-4611
Mailing address
PO BOX 635151, NACOGDOCHES, TX 75963-5151
(936) 462-7844
(936) 462-7855
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
J4308
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0052NA
BLUE CROSS BLUE SHIELD
TX
05
—
179619501
—
TX
Enumeration date
11/06/2007
Last updated
11/11/2010
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