1073505814 NPI number — DR. WILLIAM E LEADINGHAM OD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073505814 NPI number — DR. WILLIAM E LEADINGHAM OD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

LEADINGHAM

Provider First Name:

WILLIAM

Provider Middle Name:

E

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

OD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

CENTER

Provider Other First Name:

NEURO VISUAL

Provider Other Middle Name:

REHABILITATION

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

OD

Provider Other Last Name Type Code:

5

NPI Number:

1073505814

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/28/2012

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 2005

Provider Second Line Business Mailing Address:

STE 3

Provider Business Mailing Address City Name:

ASHLAND

Provider Business Mailing Address State Name:

KY

Provider Business Mailing Address Postal Code:

41105-2005

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

606-329-8672

Provider Business Mailing Address Fax Number:

606-329-1258

Provider First Line Business Practice Location Address:

1330 CARTER AVE

Provider Second Line Business Practice Location Address:

STE 3

Provider Business Practice Location Address City Name:

ASHLAND

Provider Business Practice Location Address State Name:

KY

Provider Business Practice Location Address Postal Code:

41101-7544

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

606-329-1258

Provider Business Practice Location Address Fax Number:

606-329-1258

Provider Enumeration Date:

08/18/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 152W00000X , with the licence number:  748-DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 152WS0006X , with the licence number: 748-DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 152WV0400X , with the licence number: 748-DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 2202261 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 0149565-001 . This is a "MEDICAID" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: KY00748 . This is a "VISION BENEFITS OF AMER." identifier . This identifiers is of the category "OTHER".
• Identifier: 181142 . This is a "NATIONAL VISION ADMIN." identifier . This identifiers is of the category "OTHER".
• Identifier: P00058622 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: DA4299 . This is a "RAILROAD MEDICARE (GROUP)" identifier . This identifiers is of the category "OTHER".
• Identifier: 4904360001 . This is a "OMERC" identifier . This identifiers is of the category "OTHER".
• Identifier: 000000305764 . This is a "ANTHEM BLUECROSS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 0005282086 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 77903664 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".