Provider Demographics
NPI:1992773345
Name:TRIMBLE, LESLIE RENE (OD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:RENE
Last Name:TRIMBLE
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 1:435 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-6614
Mailing Address - Country:US
Mailing Address - Phone:918-687-4459
Mailing Address - Fax:918-687-0238
Practice Address - Street 1:435 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-6614
Practice Address - Country:US
Practice Address - Phone:918-687-4459
Practice Address - Fax:918-687-0238
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2289152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKM1419063243Medicaid
U76154Medicare UPIN