Provider Demographics
NPI:1104814425
Name:LEIDENIX, MONTE JOHN (MD FACS)
Entity type:Individual
Prefix:DR
First Name:MONTE
Middle Name:JOHN
Last Name:LEIDENIX
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4112
Mailing Address - Country:US
Mailing Address - Phone:701-255-4673
Mailing Address - Fax:701-255-4934
Practice Address - Street 1:620 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4112
Practice Address - Country:US
Practice Address - Phone:701-255-4673
Practice Address - Fax:701-255-4934
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7678207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10199Medicaid
SD7780550Medicaid
MT10354900Medicaid
ND14737OtherBLUE SHIELD PROVIDER #
ND14737OtherBLUE SHIELD PROVIDER #
NDG45819Medicare UPIN