Provider Demographics
NPI:1922185123
Name:CRADDOCK, LESLIE E (OD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:E
Last Name:CRADDOCK
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 1:6239 WOODLAWN AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-5716
Mailing Address - Country:US
Mailing Address - Phone:206-588-2814
Mailing Address - Fax:206-432-9751
Practice Address - Street 1:6239 WOODLAWN AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-5716
Practice Address - Country:US
Practice Address - Phone:206-588-2814
Practice Address - Fax:206-432-9751
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3081152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8897961OtherMEDICARE/ ORGANIZATIONAL PTAN
WAG8897960OtherPTAN
WAG8897961OtherMEDICARE/ ORGANIZATIONAL PTAN
WA201881342OtherTAX ID