Provider Demographics
NPI:1073580916
Name:GILLIAM, LESLIE SHANE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:SHANE
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E FREY ST STE 201
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-2600
Mailing Address - Country:US
Mailing Address - Phone:254-965-2313
Mailing Address - Fax:254-965-2363
Practice Address - Street 1:205 E FREY ST STE 201
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-2600
Practice Address - Country:US
Practice Address - Phone:254-965-2313
Practice Address - Fax:254-965-2363
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI01752Medicare UPIN