Basic Information
| Provider Information | |||||||||
| NPI: | 1497767420 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEATH | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 3410 FAR WEST BLVD | ||||||||
| Address2: | SUITE 146 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787313194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123490777 | ||||||||
| FaxNumber: | 5123499111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | M4273 | TX | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy | 2080P0201X | M4273 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology | 207K00000X | M4273 | TX | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 752741 | 01 | TX | MEDICARE PTAN | OTHER |