Provider Demographics
NPI:1831229913
Name:INGHAM, LEON D (OD)
Entity type:Individual
Prefix:DR
First Name:LEON
Middle Name:D
Last Name:INGHAM
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 1:1941 STATE PARK RD
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-9416
Mailing Address - Country:US
Mailing Address - Phone:810-715-1650
Mailing Address - Fax:
Practice Address - Street 1:3700 OWEN RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-9193
Practice Address - Country:US
Practice Address - Phone:810-750-7345
Practice Address - Fax:810-750-7364
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004060152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU82244Medicare UPIN
MION19170Medicare ID - Type Unspecified