Provider Demographics
NPI:1093835464
Name:LEBLANC, MISTY BROOKE (OD)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:BROOKE
Last Name:LEBLANC
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 1:1916 N HOBART ST
Mailing Address - Street 2:
Mailing Address - City:PAMPA
Mailing Address - State:TX
Mailing Address - Zip Code:79065-3413
Mailing Address - Country:US
Mailing Address - Phone:806-669-2824
Mailing Address - Fax:806-669-3586
Practice Address - Street 1:1916 N HOBART ST
Practice Address - Street 2:
Practice Address - City:PAMPA
Practice Address - State:TX
Practice Address - Zip Code:79065-3413
Practice Address - Country:US
Practice Address - Phone:806-669-2824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6512TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU99747Medicare UPIN
TX8K0411Medicare PIN
TX8L13831Medicare PIN