Provider Demographics
NPI:1659668978
Name:LEBURG, ELIZABETH MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MARIE
Last Name:LEBURG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:MARIE
Other - Last Name:METZGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:9795 CROSSPOINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3354
Mailing Address - Country:US
Mailing Address - Phone:317-254-6480
Mailing Address - Fax:317-259-8609
Practice Address - Street 1:105 S RACEWAY RD
Practice Address - Street 2:STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46231-1414
Practice Address - Country:US
Practice Address - Phone:317-273-8474
Practice Address - Fax:317-259-8609
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003676A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400051858Medicare PIN