Provider Demographics
NPI:1326100298
Name:HACKWORTH, LESLIE ALLYSON (OD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ALLYSON
Last Name:HACKWORTH
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:HC01 BOX 8150
Mailing Address - Street 2:SAN SIMON INDIAN HEALTH CENTER
Mailing Address - City:SELLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85634-9737
Mailing Address - Country:US
Mailing Address - Phone:520-235-0344
Mailing Address - Fax:520-363-7080
Practice Address - Street 1:HWY 86, MILE MARKER 74
Practice Address - Street 2:EYE CLINIC, SAN SIMON INDIAN HEALTH CENTER
Practice Address - City:N/A
Practice Address - State:AZ
Practice Address - Zip Code:85634-9716
Practice Address - Country:US
Practice Address - Phone:520-235-0344
Practice Address - Fax:520-362-7080
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002586152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004237097Medicaid
CTD400003697Medicare PIN
CT004237097Medicaid