Provider Demographics
NPI:1598714321
Name:LEIBSTEIN, DAVID LANE (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LANE
Last Name:LEIBSTEIN
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 1:3074 MESSICK AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-2946
Mailing Address - Country:US
Mailing Address - Phone:516-993-0452
Mailing Address - Fax:516-536-4322
Practice Address - Street 1:202 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2727
Practice Address - Country:US
Practice Address - Phone:631-264-3937
Practice Address - Fax:631-598-4496
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005756-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01801761Medicaid
NYC26211Medicare PIN
NY01801761Medicaid