Provider Demographics
NPI:1609352368
Name:GIBSON, LESLIE SUZANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:SUZANNE
Last Name:GIBSON
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 1:218 E LOYALHANNA ST
Mailing Address - Street 2:
Mailing Address - City:LIGONIER
Mailing Address - State:PA
Mailing Address - Zip Code:15658-1316
Mailing Address - Country:US
Mailing Address - Phone:724-858-9121
Mailing Address - Fax:
Practice Address - Street 1:1225 S MAIN ST STE 307
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-5370
Practice Address - Country:US
Practice Address - Phone:724-838-7361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003423152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist