Provider Demographics
NPI:1316964356
Name:LEESE, KENNETH H (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:LEESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:500 GROVE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1761
Mailing Address - Country:US
Mailing Address - Phone:856-796-9200
Mailing Address - Fax:856-796-7397
Practice Address - Street 1:1600 HADDON AVE
Practice Address - Street 2:WOUND CARE
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3101
Practice Address - Country:US
Practice Address - Phone:856-546-3900
Practice Address - Fax:856-546-3908
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2015-01-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA02077500208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3034003Medicaid
D19415Medicare UPIN
NJ3034003Medicaid