Provider Demographics
NPI:1851402598
Name:WHITE, LESLIE W (OD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:W
Last Name:WHITE
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: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
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK872152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731001801OtherFEDERAL TAX ID
OK100762540 AMedicaid
OK731001801Medicare ID - Type Unspecified
OK100762540 AMedicaid
OK731001801OtherFEDERAL TAX ID