Provider Demographics
NPI:1699876417
Name:MASCIARELLI KISCH, LESLIE R (OD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:R
Last Name:MASCIARELLI KISCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:LESLIE
Other - Middle Name:R
Other - Last Name:MASCIARELLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:706 12TH ST SE
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56514-3960
Mailing Address - Country:US
Mailing Address - Phone:218-354-7065
Mailing Address - Fax:
Practice Address - Street 1:918 WASHINGTON AVE
Practice Address - Street 2:OPTICAL EYEDEAS
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501
Practice Address - Country:US
Practice Address - Phone:218-847-8021
Practice Address - Fax:218-846-9552
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2319152W00000X
ND490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2202047OtherMEDICA
MN36B56MAOtherBCBS
MN2202048OtherMEDICA
MN2207652OtherMEDICA
MN283R7MAOtherBCBS
MN283R8MAOtherBCBS
MN283R8MAOtherBCBS