Provider Demographics
NPI:1578887485
Name:LESLIE DRAPER OD PC
Entity Type:Organization
Organization Name:LESLIE DRAPER OD PC
Other - Org Name:DR. LESLIE DRAPER, CHATTANOOGA EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIC PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-468-3305
Mailing Address - Street 1:1201 MARKET ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-2714
Mailing Address - Country:US
Mailing Address - Phone:423-468-3305
Mailing Address - Fax:423-468-3319
Practice Address - Street 1:1201 MARKET ST
Practice Address - Street 2:STE B
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-2714
Practice Address - Country:US
Practice Address - Phone:423-883-2535
Practice Address - Fax:423-468-3319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3590042Medicaid
TN103G414892Medicare PIN
TN3590042Medicaid