Provider Demographics
NPI:1467460014
Name:EMMERT-BUCK, LESLIE T (MD, PHD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:T
Last Name:EMMERT-BUCK
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 N SQUIRREL RD STE 202
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-2871
Mailing Address - Country:US
Mailing Address - Phone:443-415-9024
Mailing Address - Fax:248-710-0056
Practice Address - Street 1:691 N SQUIRREL RD STE 202
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2871
Practice Address - Country:US
Practice Address - Phone:248-710-0063
Practice Address - Fax:248-710-0056
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301111051207WX0120X, 207W00000X
MDD00061983207WX0120X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406796700Medicaid
MDH87906Medicare UPIN