Provider Demographics
NPI:1285770065
Name:LEISCHER, GREGORY LEE (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LEE
Last Name:LEISCHER
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 1:611 STEVENS DRIVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3006
Mailing Address - Country:US
Mailing Address - Phone:715-848-2020
Mailing Address - Fax:715-845-6669
Practice Address - Street 1:611 STEVENS DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-3006
Practice Address - Country:US
Practice Address - Phone:715-848-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38601100Medicaid
WI38601100Medicaid
WI4900830001OtherNSC EYECARE CTR OF WAUSAU
WI6210500001Medicare NSC
WI4900830001OtherNSC EYECARE CTR OF WAUSAU
WI00247755Medicare ID - Type Unspecified