Provider Demographics
NPI:1821239005
Name:LEASE EYE MD PC
Entity Type:Organization
Organization Name:LEASE EYE MD PC
Other - Org Name:ST ANTHONY EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOU
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KIESSLING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-792-8255
Mailing Address - Street 1:405 S CLARK ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3065
Mailing Address - Country:US
Mailing Address - Phone:712-792-8255
Mailing Address - Fax:712-792-8256
Practice Address - Street 1:405 S CLARK ST
Practice Address - Street 2:SUITE 220
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3065
Practice Address - Country:US
Practice Address - Phone:712-792-8255
Practice Address - Fax:712-792-8256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31091207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1139030Medicaid
IA45445OtherBCBS
IA45445Medicare PIN
IA45445OtherBCBS