Provider Demographics
NPI:1992798052
Name:CHURCH, LESLIE ANN (OD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ANN
Last Name:CHURCH
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 1:27607 STATE ROAD 56
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-8834
Mailing Address - Country:US
Mailing Address - Phone:813-406-4993
Mailing Address - Fax:813-406-4997
Practice Address - Street 1:27607 STATE ROAD 56
Practice Address - Street 2:SUITE 101
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-8834
Practice Address - Country:US
Practice Address - Phone:813-406-4993
Practice Address - Fax:813-406-4997
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3438152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620574700Medicaid
FL620574700Medicaid
FL20973WMedicare PIN
FLU85580Medicare UPIN