Provider Demographics
NPI:1205879855
Name:LEACH, CHARLES RAYMOND (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RAYMOND
Last Name:LEACH
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 1:4440 E HIGHWAY 287
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-5576
Mailing Address - Country:US
Mailing Address - Phone:972-723-5590
Mailing Address - Fax:972-723-5592
Practice Address - Street 1:4440 E HIGHWAY 287
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-5576
Practice Address - Country:US
Practice Address - Phone:972-723-5590
Practice Address - Fax:972-723-5592
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4922207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131879208Medicaid
TX283520YL7AOtherMEDICARE - OTHER COUNTY
TX131879204Medicaid
TX131879221OtherMEDICAID OTHER
TX110094182OtherRAILROAD MEDICARE
TX131879218Medicaid
TX131879218Medicaid
TXTXB103777Medicare PIN
TX283520YL7BMedicare PIN
TX110094182OtherRAILROAD MEDICARE
TX131879204Medicaid
TXP00760081Medicare PIN
TXC18226Medicare UPIN
TX131879208Medicaid