Provider Demographics
NPI:1124122643
Name:LEISER, JEFFREY D (MD, PHD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:LEISER
Suffix:
Gender:M
Credentials:MD, PHD
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 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RR 230
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-274-2563
Practice Address - Fax:317-278-3599
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010420662080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64882772Medicaid
IN100379290Medicaid
IN100379290Medicaid
145590VVMedicare ID - Type Unspecified