Provider Demographics
NPI:1306816962
Name:WALSH, LESLIE LENNOX (DO)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:LENNOX
Last Name:WALSH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 S LIVERNOIS
Mailing Address - Street 2:SUITE 190
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2591
Mailing Address - Country:US
Mailing Address - Phone:248-656-9696
Mailing Address - Fax:
Practice Address - Street 1:1101 W UNIVERSITY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307
Practice Address - Country:US
Practice Address - Phone:248-652-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008152207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114170869Medicaid
B69426Medicare UPIN
MI114170869Medicaid