Provider Demographics
NPI:1528623352
Name:LEASURE, JUSTIN M (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:LEASURE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:4141 SHORE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2607
Practice Address - Country:US
Practice Address - Phone:317-329-2525
Practice Address - Fax:317-329-2525
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2024-10-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01093738A208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300042756Medicaid