Provider Demographics
NPI:1790868719
Name:LESLIE WHITE O D INC
Entity Type:Organization
Organization Name:LESLIE WHITE O D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-225-1548
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-0670
Mailing Address - Country:US
Mailing Address - Phone:918-225-1548
Mailing Address - Fax:918-225-1548
Practice Address - Street 1:126 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4115
Practice Address - Country:US
Practice Address - Phone:918-225-1548
Practice Address - Fax:918-225-1548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK872152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100762540AMedicaid
OK=========OtherFEDERAL TAX ID
OKT40710Medicare UPIN
OK=========OtherFEDERAL TAX ID
OK=========Medicare ID - Type Unspecified
OK0222960001Medicare NSC