Provider Demographics
NPI:1154367738
Name:LEATHERMAN, BRYAN DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DAVID
Last Name:LEATHERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-1918
Mailing Address - Country:US
Mailing Address - Phone:228-896-2896
Mailing Address - Fax:
Practice Address - Street 1:1213 BROAD AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2475
Practice Address - Country:US
Practice Address - Phone:228-864-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17564207Y00000X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Not Answered207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02361Medicare ID - Type Unspecified
MSH60691Medicare UPIN