Provider Demographics
NPI:1952378945
Name:LEECH, THOMAS GENE (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GENE
Last Name:LEECH
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 1:2282 NW TROOST ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-6071
Mailing Address - Country:US
Mailing Address - Phone:541-672-7428
Mailing Address - Fax:541-672-7430
Practice Address - Street 1:2282 NW TROOST ST
Practice Address - Street 2:SUITE 104
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6071
Practice Address - Country:US
Practice Address - Phone:541-672-7428
Practice Address - Fax:541-672-7430
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1490T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR264523Medicaid
OR264523Medicaid
ORR116397Medicare ID - Type Unspecified