Provider Demographics
NPI:1306191218
Name:LEONARD, BEN
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:LEONARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 INDUSTRIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:CALVERT CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42029-8416
Mailing Address - Country:US
Mailing Address - Phone:270-395-8331
Mailing Address - Fax:
Practice Address - Street 1:43 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:CALVERT CITY
Practice Address - State:KY
Practice Address - Zip Code:42029-8416
Practice Address - Country:US
Practice Address - Phone:270-395-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1896DT152W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000781207OtherANTHEM
KY7100215320Medicaid
KYK156331Medicare PIN