Provider Demographics
NPI:1902876303
Name:AFFOLTER, LEROY (OD)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:
Last Name:AFFOLTER
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 1:121 N 3RD ST
Mailing Address - Street 2:PO BOX 60
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1324
Mailing Address - Country:US
Mailing Address - Phone:507-532-5143
Mailing Address - Fax:507-532-5143
Practice Address - Street 1:121 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-1324
Practice Address - Country:US
Practice Address - Phone:507-532-5143
Practice Address - Fax:507-532-5143
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1370MN152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN17150OtherSIOUX VALLEY HEALTH PLAN
MN2882361OtherMEDICA
MN46009AFOtherBCBS
MN930531027150OtherPREFERRED ONE
MN633523300Medicaid
MN11257OtherUCARE
MN410049342OtherRAILROAD MEDICARE
MN5C002AFOtherBCBS DURABLE GOODS
MN331040887OtherALL OTHER
MN331040887OtherALL OTHER
MN2882361OtherMEDICA
MN46009AFOtherBCBS