Provider Demographics
NPI:1134101397
Name:THORNBURG, LESLIE D (OD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:D
Last Name:THORNBURG
Suffix:
Gender:M
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:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-0446
Mailing Address - Country:US
Mailing Address - Phone:715-635-3127
Mailing Address - Fax:715-635-3316
Practice Address - Street 1:W7164 GREEN VALLEY RD
Practice Address - Street 2:INDIANHEAD EYE CLINIC
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-6605
Practice Address - Country:US
Practice Address - Phone:715-635-3127
Practice Address - Fax:715-635-3316
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1515035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38561400Medicaid
410028270OtherPALMETTO RR MEDICARE
WI38561400Medicaid
000187430Medicare PIN