Provider Demographics
NPI:1154416857
Name:LEEDY, JASON E (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:E
Last Name:LEEDY
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:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44061-0660
Mailing Address - Country:US
Mailing Address - Phone:440-854-0217
Mailing Address - Fax:440-461-1440
Practice Address - Street 1:2060 LANDER RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-4100
Practice Address - Country:US
Practice Address - Phone:440-461-6100
Practice Address - Fax:440-461-1440
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350852662086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000376503OtherANTHEM BLUE SHIELD
OHR85266OtherSUMMACARE
OH2598916Medicaid
OHR85266OtherSUMMACARE
OH000000376503OtherANTHEM BLUE SHIELD
OHP00262566Medicare PIN