Provider Demographics
NPI:1548456064
Name:CLARY, LESLIE MITCHELL (O D)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:MITCHELL
Last Name:CLARY
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 E 71ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-5038
Mailing Address - Country:US
Mailing Address - Phone:918-446-3171
Mailing Address - Fax:918-446-5938
Practice Address - Street 1:1425 E 71ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5038
Practice Address - Country:US
Practice Address - Phone:918-446-3171
Practice Address - Fax:918-446-5938
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200120640AMedicaid
OKCO5028OtherRR MEDICARE
OK200120640AMedicaid
OKTRIADEYEMedicare PIN
OK243729204Medicare PIN
OKCO5028OtherRR MEDICARE
OKOK400576Medicare PIN
OKOK71159Medicare PIN