Provider Demographics
NPI:1699745851
Name:LEBER, DAN (OD)
Entity type:Individual
Prefix:DR
First Name:DAN
Middle Name:
Last Name:LEBER
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 1:20542 N LAKE PLEASANT RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9749
Mailing Address - Country:US
Mailing Address - Phone:632-572-9090
Mailing Address - Fax:623-572-9797
Practice Address - Street 1:20542 N LAKE PLEASANT RD
Practice Address - Street 2:SUITE 107
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9749
Practice Address - Country:US
Practice Address - Phone:632-572-9090
Practice Address - Fax:623-572-9797
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ775152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ173708Medicaid
AZ68558Medicare ID - Type Unspecified
AZWCKHS12Medicare ID - Type Unspecified
AZ68560Medicare ID - Type Unspecified
AZWCKJPMedicare ID - Type Unspecified
AZ67127Medicare ID - Type Unspecified
AZ68559Medicare ID - Type Unspecified
AZ173708Medicaid