Provider Demographics
NPI:1710430673
Name:PURVIS, LEIGH (OD)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:
Last Name:PURVIS
Suffix:
Gender:F
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:PO BOX 80817
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29416-0817
Mailing Address - Country:US
Mailing Address - Phone:843-556-2020
Mailing Address - Fax:
Practice Address - Street 1:1470 TOBIAS GADSON BLVD STE 115
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4835
Practice Address - Country:US
Practice Address - Phone:843-556-2020
Practice Address - Fax:843-763-3937
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003244152W00000X
FLOFC77152W00000X
SCOPT1981152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018916600Medicaid