Provider Demographics
NPI:1548315021
Name:LEIB, RONALD JAY (DPM)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:JAY
Last Name:LEIB
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 1:39 S VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-5826
Mailing Address - Country:US
Mailing Address - Phone:815-477-9221
Mailing Address - Fax:815-477-8916
Practice Address - Street 1:39 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-5826
Practice Address - Country:US
Practice Address - Phone:815-477-9221
Practice Address - Fax:815-477-8916
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5619947OtherBC BS OF ILLINOIS
ILT34186Medicare UPIN
IL360620Medicare ID - Type UnspecifiedMEDICARE ILLINOIS NUMBER