Provider Demographics
NPI:1104486885
Name:LEEBOLT, ANDREW T (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:T
Last Name:LEEBOLT
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BRIGHTWATER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546
Mailing Address - Country:US
Mailing Address - Phone:910-892-1000
Mailing Address - Fax:
Practice Address - Street 1:215 BRIGHTWATER DRIVE
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546
Practice Address - Country:US
Practice Address - Phone:910-892-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-16
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5357207P00000X, 207Q00000X
VA0102208637207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine