Provider Demographics
NPI:1790758142
Name:SHERLOCK, LELAND J (OD)
Entity Type:Individual
Prefix:
First Name:LELAND
Middle Name:J
Last Name:SHERLOCK
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 1:2610 E UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-8436
Mailing Address - Country:US
Mailing Address - Phone:480-892-8400
Mailing Address - Fax:480-892-9533
Practice Address - Street 1:4760 E FALCON DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-2528
Practice Address - Country:US
Practice Address - Phone:480-985-7400
Practice Address - Fax:480-396-6362
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ754152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWCGPB14Medicare PIN
AZZ41WCGFR13Medicare PIN
AZU42379Medicare UPIN