Provider Demographics
NPI:1649387549
Name:LEAK, BRIAN A (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:LEAK
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 1:11086 SE OAK STREET
Mailing Address - Street 2:EYE HEALTH NORTHWEST
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:503-344-5102
Mailing Address - Fax:503-344-5110
Practice Address - Street 1:6111 NE CORNELL RD
Practice Address - Street 2:EYE HEALTH NORTHWEST
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5410
Practice Address - Country:US
Practice Address - Phone:503-846-9400
Practice Address - Fax:503-846-9500
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3300ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500607965Medicaid
ORR147501Medicare PIN
KYVAD000Medicare UPIN