Provider Demographics
NPI:1396019121
Name:LEESUE, GARY (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:LEESUE
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 1:3070 NW 48TH TER
Mailing Address - Street 2:APT 301
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33313-7243
Mailing Address - Country:US
Mailing Address - Phone:305-903-9239
Mailing Address - Fax:
Practice Address - Street 1:1545 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COLONIE
Practice Address - State:NY
Practice Address - Zip Code:12205-5060
Practice Address - Country:US
Practice Address - Phone:518-452-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007808-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist