Provider Demographics
NPI:1316394711
Name:LEYDA, ETHAN WALLACE (OD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:WALLACE
Last Name:LEYDA
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 1:6284 WAYNESBURG RD NW
Mailing Address - Street 2:
Mailing Address - City:WAYNESBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44688-9410
Mailing Address - Country:US
Mailing Address - Phone:330-605-9851
Mailing Address - Fax:
Practice Address - Street 1:10701 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1702
Practice Address - Country:US
Practice Address - Phone:216-791-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH6476152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program