Basic Information
| Provider Information | |||||||||
| NPI: | 1255330940 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEEAH | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9601 SPUR 591 | ||||||||
| Address2: | WILLIAM P. CLEMENTS, JR. UNIT | ||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791079606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063817080 | ||||||||
| FaxNumber: | 8063810417 | ||||||||
| Practice Location | |||||||||
| Address1: | 9601 SPUR 591 | ||||||||
| Address2: | WILLIAM P. CLEMENTS, JR. UNIT | ||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791079606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063817080 | ||||||||
| FaxNumber: | 8063810417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 06/14/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | L5020 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0016KH | 01 | TX | BCBS | OTHER | L5020 | 01 | TX | STATE MEDICAL LICENSE | OTHER | 680574937 | 01 | TX | TAX ID | OTHER | 159401201 | 05 | TX | MEDICAID | BL8025149 | 01 | TX | DEA PRESCRIBER NUMBER | OTHER | 007614479 | 01 | TX | AETNA | OTHER |