Provider Demographics
NPI:1154841070
Name:ANDERSON, LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:ANDERSON
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 1:611 W PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3313
Practice Address - Fax:217-383-4014
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036155016207P00000X
IL125.071313207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine