Provider Demographics
NPI:1245280379
Name:LEONARD, ROSS ALBERT (DPM)
Entity type:Individual
Prefix:DR
First Name:ROSS
Middle Name:ALBERT
Last Name:LEONARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 CLAIRMONT DR STE A
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1136
Mailing Address - Country:US
Mailing Address - Phone:541-850-6463
Mailing Address - Fax:541-850-5990
Practice Address - Street 1:2300 CLAIRMONT DR STE A
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1136
Practice Address - Country:US
Practice Address - Phone:541-850-6463
Practice Address - Fax:541-850-5990
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00138213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH252901OtherPACIFIC SOURCE ID
OR229716Medicaid
OR14538XXOtherPREFERRED CARE ID
OR008599000OtherBLUE CROSS ID
OR0902467OtherWPS TRICARE ID
OR480001063Medicare ID - Type UnspecifiedRAILROAD MC ID
OROOOOSGBFQMedicare ID - Type UnspecifiedMEDICARE PROVIDER ID
OR229716Medicaid
OR008599000OtherBLUE CROSS ID
OR14538XXOtherPREFERRED CARE ID