MEDICARE: DR. DONALD B LEACH 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	245OP2245	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NM00P054	OTHER	NM	BLUECROSS BLUESHIELD
2	10007839	OTHER	NM	LOVELACE HEALTH, SR
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578561312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONALD B LEACH O.D.

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

Provider Business Practice Location Address
First Line	:	943 MAIN STREET S.W.
Second Line	:	LOS OJOS PROFESSIONAL BLDG
City	:	LOS LUNAS
State	:	NM
Zip	:	87031
Country	:	US
Telephone Number	:	505-865-4812
Fax Number	:	505-865-3767

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

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	03/28/2008

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