Provider Demographics
NPI:1174591507
Name:BUSBY, LESLIE VERNER (OD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:VERNER
Last Name:BUSBY
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 1:1209 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6727
Mailing Address - Country:US
Mailing Address - Phone:575-437-9326
Mailing Address - Fax:575-434-6995
Practice Address - Street 1:1209 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6727
Practice Address - Country:US
Practice Address - Phone:575-437-9326
Practice Address - Fax:575-434-6995
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOP2207152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2590491Medicare PIN
NMT74934Medicare UPIN