Provider Demographics
NPI:1841295367
Name:LEITNER, ROBERT W (OD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:LEITNER
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 1:3526 WEXFORD DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-2020
Mailing Address - Country:US
Mailing Address - Phone:229-888-3298
Mailing Address - Fax:
Practice Address - Street 1:716 E 16TH AVE STE C
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-4517
Practice Address - Country:US
Practice Address - Phone:229-273-2395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000985152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00695395AMedicaid
GA41ZCCXHMedicare ID - Type Unspecified
GA00695395AMedicaid
CI4690Medicare PIN
410038734Medicare PIN
GAT40541Medicare UPIN
CM6672Medicare PIN