Provider Demographics
NPI:1932107513
Name:LEEPER, JEFFREY ALLEN (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALLEN
Last Name:LEEPER
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 1:213 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:IA
Mailing Address - Zip Code:52136-1521
Mailing Address - Country:US
Mailing Address - Phone:563-547-5363
Mailing Address - Fax:563-547-2621
Practice Address - Street 1:213 N ELM ST
Practice Address - Street 2:
Practice Address - City:CRESCO
Practice Address - State:IA
Practice Address - Zip Code:52136-1521
Practice Address - Country:US
Practice Address - Phone:563-547-5363
Practice Address - Fax:563-547-2621
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01837152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2233122Medicaid
IA5185110001Medicare NSC
IAI12325Medicare ID - Type Unspecified
IA2233122Medicaid