Provider Demographics
NPI:1396746491
Name:LEACH, TIMOTHY JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:LEACH
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 1:3200 SEVERN AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-4793
Mailing Address - Country:US
Mailing Address - Phone:504-887-2020
Mailing Address - Fax:504-887-7698
Practice Address - Street 1:433 SPORTSPLEX DR STE 100
Practice Address - Street 2:
Practice Address - City:DRIPPING SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:78620-5359
Practice Address - Country:US
Practice Address - Phone:512-858-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1241-391T152W00000X
TX7174TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1698644Medicaid
LA4B230Medicare PIN
LAU67440Medicare UPIN