Provider Demographics
NPI:1205836897
Name:LINDQUIST, SLADE ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:SLADE
Middle Name:ALLEN
Last Name:LINDQUIST
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 1:550 POPE AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-2332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:402-203-7533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1164152W00000X, 152WV0400X, 152WX0102X, 152WL0500X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEP01561496OtherRAILROAD MEDICARE
NE100249543-00Medicaid
NENA2829Medicare PIN
NEU91558Medicare UPIN
NE37136OtherBSBSNE
NE4110049441OtherRAILROAD MEDICARE
NE36393OtherBSBSNE
NE238417OtherMIDLANDS CHOICE
NE77754372OtherAETNA
NE100249543-00Medicaid