Provider Demographics
NPI:1992814404
Name:LEACH, TERRY R (OD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:R
Last Name:LEACH
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 1:2865 CHANCELLOR DR
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3912
Mailing Address - Country:US
Mailing Address - Phone:859-344-2079
Mailing Address - Fax:859-581-7207
Practice Address - Street 1:1577 GOODMAN AVE STE B
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45224-1044
Practice Address - Country:US
Practice Address - Phone:513-729-1321
Practice Address - Fax:513-729-2873
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4416152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0095608Medicaid
OHH524380Medicare PIN
U53908Medicare UPIN
U53908Medicare UPIN
1821136177OtherGROUP NPI
311645431OtherU.H.C.
311645431OtherHUMANA