Provider Demographics
NPI:1861401796
Name:FROM, LELAND J (MD)
Entity type:Individual
Prefix:
First Name:LELAND
Middle Name:J
Last Name:FROM
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 1:1969 W HART RD
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2230
Mailing Address - Country:US
Mailing Address - Phone:608-363-5985
Mailing Address - Fax:608-364-5452
Practice Address - Street 1:1969 W HART RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2230
Practice Address - Country:US
Practice Address - Phone:608-363-5985
Practice Address - Fax:608-364-5452
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2009-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23638020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10638OtherDEAN HEALTH PLAN HMO
WI30396900Medicaid
WI000054275Medicare ID - Type Unspecified
WI30396900Medicaid