Basic Information
| Provider Information | |||||||||
| NPI: | 1992179832 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAY LEATHERS MD INC | ||||||||
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| OtherOrganizationName: | LEATHERSMD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4676 LAKEVIEW AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | YORBA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928862489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149303096 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4676 LAKEVIEW AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | YORBA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928862489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149303096 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2015 | ||||||||
| LastUpdateDate: | 11/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEATHERS | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7149303096 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A121700 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.