Provider Demographics
NPI:1629027958
Name:LEAHY, TIMOTHY J (OD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:LEAHY
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 1:201 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62363-1447
Mailing Address - Country:US
Mailing Address - Phone:217-285-4800
Mailing Address - Fax:217-285-4850
Practice Address - Street 1:201 N MADISON ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1447
Practice Address - Country:US
Practice Address - Phone:217-285-4800
Practice Address - Fax:217-285-4850
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000146553152W00000X
IL046008656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1629027958Medicaid
MO1629027958Medicaid
IL21383OtherHEALTH ALLIANCE
IL0460086561Medicaid
IL21383OtherHEALTH ALLIANCE
IL410028249Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IL0460086561Medicaid
IL046008656Medicaid