Provider Demographics
NPI:1578572442
Name:WILDERSON, LESLIE RAND (OD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:RAND
Last Name:WILDERSON
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 1:2300 PINE ST
Mailing Address - Street 2:#7
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6438
Mailing Address - Country:US
Mailing Address - Phone:215-490-8090
Mailing Address - Fax:
Practice Address - Street 1:1250 BALTIMORE PIKE
Practice Address - Street 2:PEARLE VISION
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-2706
Practice Address - Country:US
Practice Address - Phone:610-544-1841
Practice Address - Fax:610-544-2984
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOET008830152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPENDINGMedicaid
FLU72214Medicare UPIN
FL410047974Medicare ID - Type UnspecifiedRAILROAD
PAPENDINGMedicare PIN