Provider Demographics
NPI:1184724296
Name:COFFEE GALLAGHER, LESLIE (OD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:COFFEE GALLAGHER
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 1:121 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLTON
Mailing Address - State:KS
Mailing Address - Zip Code:66436-1701
Mailing Address - Country:US
Mailing Address - Phone:785-364-5036
Mailing Address - Fax:785-364-5473
Practice Address - Street 1:121 W 4TH ST
Practice Address - Street 2:
Practice Address - City:HOLTON
Practice Address - State:KS
Practice Address - Zip Code:66436-1701
Practice Address - Country:US
Practice Address - Phone:785-364-5000
Practice Address - Fax:785-364-5473
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS1648152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSU92498Medicare UPIN
KS651070Medicare ID - Type Unspecified