Provider Demographics
NPI:1285733204
Name:SHOUSE, LEROY (MD)
Entity type:Individual
Prefix:DR
First Name:LEROY
Middle Name:
Last Name:SHOUSE
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 1:1 W MCDONALD PKWY
Mailing Address - Street 2:STE 1B M
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-1138
Mailing Address - Country:US
Mailing Address - Phone:606-564-3351
Mailing Address - Fax:606-564-5631
Practice Address - Street 1:1 W MCDONALD PKWY
Practice Address - Street 2:STE 1B
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-1138
Practice Address - Country:US
Practice Address - Phone:606-564-3351
Practice Address - Fax:606-564-5631
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18295207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64182959Medicaid
KY1052001Medicare ID - Type Unspecified
KY64182959Medicaid