Provider Demographics
NPI:1447781315
Name:LEIGHT, TERRA (OD)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:LEIGHT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TERRA
Other - Middle Name:
Other - Last Name:REY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:559 AMETHYST LN
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-4716
Mailing Address - Country:US
Mailing Address - Phone:626-589-3945
Mailing Address - Fax:
Practice Address - Street 1:351 E TEMPLE ST # 112C
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012
Practice Address - Country:US
Practice Address - Phone:213-253-2677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33712152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist