Provider Demographics
NPI:1427086636
Name:LEAK, JAMES C (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:LEAK
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:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39631-0639
Mailing Address - Country:US
Mailing Address - Phone:601-645-5221
Mailing Address - Fax:
Practice Address - Street 1:434 N CAPTAIN GLOSTER DR
Practice Address - Street 2:
Practice Address - City:GLOSTER
Practice Address - State:MS
Practice Address - Zip Code:39638-3401
Practice Address - Country:US
Practice Address - Phone:601-225-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018128Medicaid
LA1391875Medicaid
MS00018128Medicaid
LA1391875Medicaid