Provider Demographics
NPI:1760401632
Name:LEITENBAUER, SHANNON L W CLARK (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L W CLARK
Last Name:LEITENBAUER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:CLARK LEITENBAUER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2305 OLEANDER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5830
Mailing Address - Country:US
Mailing Address - Phone:772-465-6616
Mailing Address - Fax:772-468-2858
Practice Address - Street 1:2305 OLEANDER BLVD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5830
Practice Address - Country:US
Practice Address - Phone:772-465-6616
Practice Address - Fax:772-468-2858
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC0003067152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE0050AMedicare PIN
FLU68061Medicare UPIN
FL1231240001Medicare NSC