Provider Demographics
NPI:1275995227
Name:LEECH, JOSEPH D (DO)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:D
Last Name:LEECH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY S-108
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5914
Mailing Address - Fax:601-984-5915
Practice Address - Street 1:5115 BERNARD DR STE 201
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4367
Practice Address - Country:US
Practice Address - Phone:540-345-0289
Practice Address - Fax:540-345-9569
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102206494207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1275995227Medicaid
VA1275995227Medicaid