Provider Demographics
NPI:1871561472
Name:LEOPOLD, KENNETH J (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:LEOPOLD
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:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:300 E 8TH ST
Practice Address - Street 2:SUITE 120
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3379
Practice Address - Country:US
Practice Address - Phone:740-374-4273
Practice Address - Fax:740-376-5098
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-2274207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0052657000Medicaid
OH0433061Medicaid
OH000000562031OtherANTHEM
OH0433061Medicaid
OHP00609683OtherRRMCR
OH7418861Medicare PIN
OH000000562031OtherANTHEM
OH4233161Medicare PIN