Provider Demographics
NPI:1437418019
Name:J. W, LEISY M.D.P.A.
Entity type:Organization
Organization Name:J. W, LEISY M.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEISY
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:316-681-2937
Mailing Address - Street 1:3310 EAST DOUGLAS #101
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208
Mailing Address - Country:US
Mailing Address - Phone:316-681-2937
Mailing Address - Fax:316-681-1262
Practice Address - Street 1:3310 EAST DOUGLAS #101
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208
Practice Address - Country:US
Practice Address - Phone:316-681-2937
Practice Address - Fax:316-681-1262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS145742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSB68175Medicare UPIN