Provider Demographics
NPI:1154311108
Name:WILSON, LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:WILSON
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 1:18903 HONEY MESQUITE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-1635
Mailing Address - Country:US
Mailing Address - Phone:210-573-8276
Mailing Address - Fax:
Practice Address - Street 1:3130 SE MILITARY DR STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-3892
Practice Address - Country:US
Practice Address - Phone:210-543-7334
Practice Address - Fax:210-370-3172
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7870208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics