1073784351 NPI number — DONALD B. LEACH, O.D., P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073784351 NPI number — DONALD B. LEACH, O.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DONALD B. LEACH, O.D., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073784351
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
943 MAIN STREET SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS LUNAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87031-8748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-865-4812
Provider Business Mailing Address Fax Number:
505-865-3767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
943 MAIN STREET SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS LUNAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87031-8748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-865-4812
Provider Business Practice Location Address Fax Number:
505-865-3767
Provider Enumeration Date:
03/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEACH
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT/DOCTOR
Authorized Official Telephone Number:
505-865-4812

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  245/OP2245 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 302F00000X , with the licence number: 245/OP2245 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NM00P054 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 826580615 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 201005637 . This is a "PRESBYTERIAN HEALTH, SR" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 10007839 . This is a "LOVELACE HEALTH, SR" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 999995614 . This is a "VSP" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NMB2264 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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