Provider Demographics
NPI:1316005036
Name:LEEDS, GARY EDWIN (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:EDWIN
Last Name:LEEDS
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 1:22 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-6842
Mailing Address - Country:US
Mailing Address - Phone:212-366-9112
Mailing Address - Fax:212-206-7719
Practice Address - Street 1:22 W 15TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-6842
Practice Address - Country:US
Practice Address - Phone:212-366-9112
Practice Address - Fax:212-206-7719
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYGL081A8110Medicare ID - Type Unspecified
NYB19422Medicare UPIN