Provider Demographics
NPI:1396758504
Name:MAXWELL, LEROY SR (OD MPH)
Entity type:Individual
Prefix:MR
First Name:LEROY
Middle Name:
Last Name:MAXWELL
Suffix:SR
Gender:M
Credentials:OD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-0650
Mailing Address - Country:US
Mailing Address - Phone:334-872-2321
Mailing Address - Fax:334-872-2391
Practice Address - Street 1:2401 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-7756
Practice Address - Country:US
Practice Address - Phone:334-872-2321
Practice Address - Fax:334-872-2391
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS435TA115152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000095573Medicaid
AL051095573OtherBLUE CROSS
AL000095573Medicaid
AL0126470001Medicare NSC
T68979Medicare UPIN