Provider Demographics
NPI:1639159874
Name:LEBBY, JACK (OD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:LEBBY
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 1:72840 HIGHWAY 111
Mailing Address - Street 2:STE. F197
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3324
Mailing Address - Country:US
Mailing Address - Phone:760-776-9767
Mailing Address - Fax:760-776-9333
Practice Address - Street 1:72840 HIGHWAY 111
Practice Address - Street 2:STE. F197
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3324
Practice Address - Country:US
Practice Address - Phone:760-776-9767
Practice Address - Fax:760-776-9333
Is Sole Proprietor?:No
Enumeration Date:2006-01-21
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4181152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0041810Medicare PIN