MEDICARE: LESLIE JOAN HUMPHREY O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5314/T2223	OH

General Provider Information

NPI Number	:	1255378998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE JOAN HUMPHREY O.D.

Provider Business Mailing Address
First Line	:	1108 BAUMOCK BURN DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43235-2166
Country	:	US
Telephone Number	:	614-310-5480
Fax Number	:

Provider Business Practice Location Address
First Line	:	1756 W LANE AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-3311
Country	:	US
Telephone Number	:	614-488-3937
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	04/06/2017

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