Provider Demographics
NPI:1568573574
Name:PACK, LEONARD R (OD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:R
Last Name:PACK
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 1:1217 OAK KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76117-5505
Mailing Address - Country:US
Mailing Address - Phone:817-831-6141
Mailing Address - Fax:682-647-3909
Practice Address - Street 1:1217 OAK KNOLL DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76117-5505
Practice Address - Country:US
Practice Address - Phone:817-831-6141
Practice Address - Fax:682-647-3909
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3719T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88047OtherOPTICARE PROVIDER I.D.
TX0984910001Medicare ID - Type Unspecified