Provider Demographics
NPI:1679587265
Name:LEAK-GONZALEZ, THERESA MARIE (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:LEAK-GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:260 MERRIMAC ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-2192
Mailing Address - Country:US
Mailing Address - Phone:978-499-7200
Mailing Address - Fax:978-499-7216
Practice Address - Street 1:260 MERRIMAC ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-2192
Practice Address - Country:US
Practice Address - Phone:978-499-7200
Practice Address - Fax:978-499-7216
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA235395207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0844040OtherCIGNA
MA1679587265OtherPHCS
MAJ43036OtherBCBS
MA0045415OtherNEIGHBORHOOD HEALTH PLAN
MA1679587265OtherAETNA
NH1679587265OtherANTHEM
MA1679587265OtherUNITED HEALTHCARE
MA95347501OtherNETWORK HEALTH
MAAA120030OtherHPHC
MAP00983236OtherRR MEDICARE
MA497486OtherTUFTS
MA110079874AMedicaid
NH30207840Medicaid
MA04-55814OtherEVERCARE
MA1679587265OtherBOSTON MEDICAL CENTER HEALTH PLAN
MA1679587265OtherFALLON COMMUNITY HEALTH PLAN
NH30207840Medicaid