Provider Demographics
NPI:1336140151
Name:LONG, LESLIE A (OD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:A
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOPKINS RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4641
Mailing Address - Country:US
Mailing Address - Phone:716-631-8888
Mailing Address - Fax:716-631-3803
Practice Address - Street 1:1 HOPKINS RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-4641
Practice Address - Country:US
Practice Address - Phone:716-631-8888
Practice Address - Fax:716-631-3803
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006176152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01993815Medicaid
DD4785Medicare ID - Type Unspecified
U76812Medicare UPIN