Provider Demographics
NPI:1851932826
Name:KOO, LESLIE (OD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:KOO
Suffix:
Gender:F
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 209.
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:TRINIDAD AND TOBAGO
Mailing Address - Zip Code:00000
Mailing Address - Country:TT
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 BUCCOO ROAD
Practice Address - Street 2:
Practice Address - City:MT. PLEASANT
Practice Address - State:TRINIDAD AND TOBAGO
Practice Address - Zip Code:00000
Practice Address - Country:TT
Practice Address - Phone:868-631-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist