Basic Information
| Provider Information | |||||||||
| NPI: | 1568044063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEEDS | ||||||||
| FirstName: | BLAKE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 361 HEMHILL DR | ||||||||
| Address2: | |||||||||
| City: | GALLOWAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431192200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372432636 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5100 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432281607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145441000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2021 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.