Provider Demographics
NPI:1215971775
Name:LEATHERMAN, JAMES G (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:G
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4880 CENTURY PLAZA RD
Practice Address - Street 2:SUITE 175
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5469
Practice Address - Country:US
Practice Address - Phone:317-216-2800
Practice Address - Fax:317-216-2888
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032109208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200002510Medicaid
INM400018723Medicare PIN
IN200002510Medicaid
IN144060AMedicare PIN
INE09490Medicare UPIN