Provider Demographics
NPI:1073033908
Name:COLLISON, LEAH MARIE (OD)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MARIE
Last Name:COLLISON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7455 N 95TH AVE APT 1336
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-1357
Mailing Address - Country:US
Mailing Address - Phone:218-556-6984
Mailing Address - Fax:
Practice Address - Street 1:3425 W PEORIA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4606
Practice Address - Country:US
Practice Address - Phone:602-504-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2184152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist