Provider Demographics
NPI:1922088590
Name:BRODSKY, LESLIE P (OD, FAAQ)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:P
Last Name:BRODSKY
Suffix:
Gender:M
Credentials:OD, FAAQ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-1024
Mailing Address - Country:US
Mailing Address - Phone:610-563-4036
Mailing Address - Fax:
Practice Address - Street 1:1651 THOMAS RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-1024
Practice Address - Country:US
Practice Address - Phone:610-563-4036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG00353152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102686494Medicaid
PA102686494Medicaid
PA102686494Medicaid
PA049501F2KMedicare PIN