Provider Demographics
NPI:1083711642
Name:LEYENDECKERS, MERVI HANNELE (OD)
Entity Type:Individual
Prefix:DR
First Name:MERVI
Middle Name:HANNELE
Last Name:LEYENDECKERS
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 1:926 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2748
Mailing Address - Country:US
Mailing Address - Phone:217-222-6888
Mailing Address - Fax:217-222-6975
Practice Address - Street 1:926 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2748
Practice Address - Country:US
Practice Address - Phone:217-222-6888
Practice Address - Fax:217-222-6975
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008462152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1128930001Medicare NSC
ILU33391Medicare UPIN