Provider Demographics
NPI:1083655971
Name:SEWELL, LESLIE JEAN (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:JEAN
Last Name:SEWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 HOSPITAL DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2166
Mailing Address - Country:US
Mailing Address - Phone:318-212-7848
Mailing Address - Fax:318-212-7855
Practice Address - Street 1:2300 HOSPITAL DR
Practice Address - Street 2:SUITE 320
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2166
Practice Address - Country:US
Practice Address - Phone:318-212-7848
Practice Address - Fax:318-212-7855
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021572207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1658855Medicaid
LA5W121CV09Medicare PIN
LA5W121Medicare PIN
LA1658855Medicaid