=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891295333
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEANNE LAPORTE OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2018
-----------------------------------------------------
Last Update Date | 03/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2329 COTTMAN AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19149-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-332-7228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 MONTGOMERY MALL
-----------------------------------------------------
City | NORTH WALES
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19454-3903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-361-2400
-----------------------------------------------------
Fax | 215-361-0917
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OEG003383
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------