Provider Demographics
NPI:1306116462
Name:TIMOTHY J LEACH OD A PROFESSIONAL OPTOMETRIST CORPORATION
Entity type:Organization
Organization Name:TIMOTHY J LEACH OD A PROFESSIONAL OPTOMETRIST CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:DUPLESSIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-247-9116
Mailing Address - Street 1:3200 SEVERN AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-4791
Mailing Address - Country:US
Mailing Address - Phone:504-887-2020
Mailing Address - Fax:504-887-7698
Practice Address - Street 1:3200 SEVERN AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-4791
Practice Address - Country:US
Practice Address - Phone:504-887-2020
Practice Address - Fax:504-887-7698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1241-391T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DW50Medicare PIN