Provider Demographics
NPI:1679753834
Name:BRIDGET LEESANG OD
Entity Type:Organization
Organization Name:BRIDGET LEESANG OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEESANG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:210-492-7483
Mailing Address - Street 1:4437A DE ZAVALA RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2040
Mailing Address - Country:US
Mailing Address - Phone:210-492-7483
Mailing Address - Fax:210-492-4062
Practice Address - Street 1:4437A DE ZAVALA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-2040
Practice Address - Country:US
Practice Address - Phone:210-492-7483
Practice Address - Fax:210-492-4062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5136TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU56676Medicare UPIN
TX00169SMedicare PIN