Provider Demographics
NPI:1003893124
Name:LEEDY, MARVIN E (MD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:E
Last Name:LEEDY
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 1:31 CONSERVATORY DR
Mailing Address - Street 2:
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-4281
Mailing Address - Country:US
Mailing Address - Phone:330-753-7523
Mailing Address - Fax:330-753-9162
Practice Address - Street 1:31 CONSERVATORY DR
Practice Address - Street 2:
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-4281
Practice Address - Country:US
Practice Address - Phone:330-753-7523
Practice Address - Fax:330-753-9162
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35032575L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000131917OtherANTHEM
OH0800639OtherCIGNA
OH1058OtherHOMETOWN
OH0455010Medicaid
OH0800722OtherUNITED FOOD COMMERCIAL
OH0800723OtherAETNA
OH0800638OtherUNITED HEALTHCARE
OHA79928Medicare UPIN
OHLE0491945Medicare ID - Type UnspecifiedSECONDARY LOCATION
OH0455010Medicaid