Provider Demographics
NPI:1063505667
Name:LEER, GLEN E (DO)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:E
Last Name:LEER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:IN
Mailing Address - Zip Code:46030-0383
Mailing Address - Country:US
Mailing Address - Phone:317-984-8811
Mailing Address - Fax:317-984-5862
Practice Address - Street 1:204 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:IN
Practice Address - Zip Code:46030
Practice Address - Country:US
Practice Address - Phone:317-984-8811
Practice Address - Fax:888-634-3182
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001252A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4909800001OtherMEDICARE DMEPOS
IN100319180BMedicaid
IN1343052OtherFIRST HEALTH
IN145280Medicare ID - Type Unspecified