Provider Demographics
NPI:1124427257
Name:LEBSOCK, SHAWN (OD)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:LEBSOCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-2603
Mailing Address - Country:US
Mailing Address - Phone:406-656-7505
Mailing Address - Fax:
Practice Address - Street 1:2120 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-2603
Practice Address - Country:US
Practice Address - Phone:406-656-7505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOPT-OPT-LIC-2220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist