Provider Demographics
NPI:1871653873
Name:VALENTINE, LESLIE HELEN (OD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:HELEN
Last Name:VALENTINE
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 1:852 WINTER STREET
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452
Mailing Address - Country:US
Mailing Address - Phone:601-947-3553
Mailing Address - Fax:601-947-3933
Practice Address - Street 1:852 WINTER STREET
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452
Practice Address - Country:US
Practice Address - Phone:601-947-3553
Practice Address - Fax:601-947-3933
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS639152W00000X
AL5903TA472152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880174Medicaid
U76627Medicare UPIN
MS410000203Medicare ID - Type Unspecified