Provider Demographics
NPI:1225522519
Name:LEIDHOLT, NATASHA (MD)
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:LEIDHOLT
Suffix:
Gender:F
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:PSC 475 BOX 1
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96350-1200
Mailing Address - Country:US
Mailing Address - Phone:315-370-4216
Mailing Address - Fax:
Practice Address - Street 1:PSC 475 BOX 1
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96350-1200
Practice Address - Country:US
Practice Address - Phone:315-370-4216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.167946207Q00000X
IDM-15006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine