Provider Demographics
NPI:1306005731
Name:BROOKS, LESLEY CLARK (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLEY
Middle Name:CLARK
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4856 INNOVATION DR STE B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5540
Mailing Address - Country:US
Mailing Address - Phone:970-494-4200
Mailing Address - Fax:
Practice Address - Street 1:4856 INNOVATION DR STE B
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5540
Practice Address - Country:US
Practice Address - Phone:970-494-4200
Practice Address - Fax:844-270-1824
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0049185207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO28723864Medicaid
CO28723864Medicaid
COCOAAA2513Medicare PIN