Provider Demographics
NPI:1528174059
Name:LEIDY, JOHN WILLIAM JR (MD-PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:LEIDY
Suffix:JR
Gender:M
Credentials:MD-PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1249 15TH ST DEPT MED
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3662
Mailing Address - Country:US
Mailing Address - Phone:304-691-1050
Mailing Address - Fax:
Practice Address - Street 1:1249 15TH STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE, JC EDWARDS SCHOOL OF MEDICINE
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701
Practice Address - Country:US
Practice Address - Phone:304-691-1050
Practice Address - Fax:304-429-0290
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14767207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6003532Medicaid
WVA72457Medicare UPIN
WVLE0588282Medicare ID - Type Unspecified