Provider Demographics
NPI:1124088547
Name:LEACH, STEPHEN J (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
Last Name:LEACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:37 IVAN HILL ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2001
Mailing Address - Country:US
Mailing Address - Phone:860-423-9764
Mailing Address - Fax:860-423-9866
Practice Address - Street 1:37 IVAN HILL ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2001
Practice Address - Country:US
Practice Address - Phone:860-423-9764
Practice Address - Fax:860-423-9866
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT019808207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB39440Medicare UPIN