Provider Demographics
NPI:1629644638
Name:LEYSEN, AVERY ALEXANDER (OD)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:ALEXANDER
Last Name:LEYSEN
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 1:611 WATKINS CENTRE PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-4404
Mailing Address - Country:US
Mailing Address - Phone:804-287-4200
Mailing Address - Fax:
Practice Address - Street 1:611 WATKINS CENTRE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-4404
Practice Address - Country:US
Practice Address - Phone:804-287-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618003017152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist