Provider Demographics
NPI:1225120108
Name:GRISSOM, LESLIE E (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:E
Last Name:GRISSOM
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:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1600 ROCKLAND RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-4000
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC100024802085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXPY196074Medicaid
LA1165522Medicaid
NJ5166608Medicaid
KY64195951Medicaid
ID806321200Medicaid
NY1437681Medicaid
MD7709013Medicaid
PA1197564Medicaid
IA510123Medicaid
NY1437681Medicaid
CAXPY196074Medicaid