Provider Demographics
NPI:1578561312
Name:LEACH, DONALD B (OD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:B
Last Name:LEACH
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 1:943 MAIN STREET SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-8748
Mailing Address - Country:US
Mailing Address - Phone:505-865-4812
Mailing Address - Fax:505-865-3767
Practice Address - Street 1:943 MAIN STREET S.W.
Practice Address - Street 2:LOS OJOS PROFESSIONAL BLDG
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:505-865-4812
Practice Address - Fax:505-865-3767
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM245OP2245152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00P054OtherBLUECROSS BLUESHIELD
NM10007839OtherLOVELACE HEALTH, SR
NMNMP2264Medicaid
NMT74958Medicare UPIN
NM2590950Medicare PIN
NMNM00P054OtherBLUECROSS BLUESHIELD