| Doctor Name: | KEVIN LUKE LEADHOLM |
| NPI Number: | 1124445069 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD |
| License Number: | 566036853 |
| Business Practice Address: | 111 Colchester Ave Mailstop 156sm2 Burlington, VT - 054011473 |
| Business Phone Number: | 8028474953 |
| Business Fax Number: | 8028475927 |
| Mailing Address: | 3 Academy Rd, ALBANY |
| State: | NY |
| Postal Code: | 122083102 |
| Phone Number: | 5184662623 |
| Fax Number: | |
| NPI Enumeration Date: | 03/27/2014 |
| NPI Last Update Date: | 03/27/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | 566036853 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |