Basic Information
| Provider Information | |||||||||
| NPI: | 1710096516 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LESLIE B. MILLER, O.D., INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TWIN VALLEY EYE ASSOCIATES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 HIGHLANDS DR | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | LITITZ | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175432800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176254600 | ||||||||
| FaxNumber: | 7176254676 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 HIGHLANDS DR | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | LITITZ | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175432800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176254600 | ||||||||
| FaxNumber: | 7176254676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 01/20/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST/ OWNER/ PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7176254600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OEG-001151 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1447077 | 01 | PA | PENNSYLVANIA BLUE SHIELD | OTHER | 467786 | 01 | PA | AETNA | OTHER |