Provider Demographics
NPI:1083145601
Name:DAVIS, LESLIE J (DO)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:1465 S GRAND BLVD RM 2717
Mailing Address - Street 2:SSM HEALTH CARDINAL GLENNON CHILDREN'S HOSPITAL
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-577-5634
Mailing Address - Fax:314-577-5616
Practice Address - Street 1:1465 S GRAND BLVD RM 2717
Practice Address - Street 2:1465 SOUTH GRAND BLVD, RM 2717
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5634
Practice Address - Fax:314-577-5616
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2021-03-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2020020189208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program