Provider Demographics
NPI:1881653640
Name:LECKEMBY, GARRY (OD)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:
Last Name:LECKEMBY
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 1:910 WESTBRIDGE GARDEN LANE
Mailing Address - Street 2:
Mailing Address - City:PHEONIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19760
Mailing Address - Country:US
Mailing Address - Phone:610-296-3333
Mailing Address - Fax:610-296-3030
Practice Address - Street 1:91 CHESTNUT RD
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1502
Practice Address - Country:US
Practice Address - Phone:610-296-3333
Practice Address - Fax:610-296-3030
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001072152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA465718LU5Medicare ID - Type Unspecified
PAU13193Medicare UPIN