Provider Demographics
NPI:1528056355
Name:LEATHERLAND, MARY D (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:LEATHERLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:D
Other - Last Name:HORNBECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:SHAWSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24162-0467
Mailing Address - Country:US
Mailing Address - Phone:540-268-1400
Mailing Address - Fax:540-268-1300
Practice Address - Street 1:6920 ROANOKE RD
Practice Address - Street 2:
Practice Address - City:SHAWSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24162-0467
Practice Address - Country:US
Practice Address - Phone:540-268-1400
Practice Address - Fax:540-268-1300
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA015259C95Medicare PIN
VA018050C18Medicare PIN
015256C51Medicare PIN
H17422Medicare UPIN
VA015258C47Medicare PIN