Provider Demographics
NPI:1275569089
Name:GILLUM, LESLIE A (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:A
Last Name:GILLUM
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 1:575 LENNON LN STE 152
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2443
Mailing Address - Country:US
Mailing Address - Phone:925-602-7060
Mailing Address - Fax:925-602-7070
Practice Address - Street 1:575 LENNON LN STE 152
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2443
Practice Address - Country:US
Practice Address - Phone:925-602-7060
Practice Address - Fax:925-602-7070
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA831112084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A831110Medicaid
CA00A831110Medicare PIN
CA00A831110Medicaid