Provider Demographics
NPI:1194936807
Name:MCCAULEY, LEESA DAMAR (MD)
Entity type:Individual
Prefix:DR
First Name:LEESA
Middle Name:DAMAR
Last Name:MCCAULEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LEESA
Other - Middle Name:DAMAR
Other - Last Name:HARTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:
Practice Address - Street 1:2400 17TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5351
Practice Address - Country:US
Practice Address - Phone:812-376-5974
Practice Address - Fax:812-375-3203
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57-012612207Q00000X
IN01074422A207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01074422BOtherCSR
IN01074422AOtherMEDICAL LICENSE
IN201248300AMedicaid
OH2997155Medicaid
IN000000984086OtherANTHEM PIN
IN201248300AMedicaid
IN143480001Medicare PIN
IN01074422BOtherCSR