1649387549 NPI number — BRIAN A LEAK O.D.

Table of content: BRIAN A LEAK O.D. (NPI 1649387549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649387549 NPI number — BRIAN A LEAK O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEAK
Provider First Name:
BRIAN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

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:
1649387549
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11086 SE OAK STREET
Provider Second Line Business Mailing Address:
EYE HEALTH NORTHWEST
Provider Business Mailing Address City Name:
MILWAUKIE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-344-5102
Provider Business Mailing Address Fax Number:
503-344-5110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6111 NE CORNELL RD
Provider Second Line Business Practice Location Address:
EYE HEALTH NORTHWEST
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97124-5410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-846-9400
Provider Business Practice Location Address Fax Number:
503-846-9500
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3300ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500607965 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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