Provider Demographics
NPI:1336111897
Name:JOHNSON, LESLIE E (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6339 N BIG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2908
Mailing Address - Country:US
Mailing Address - Phone:309-693-3315
Mailing Address - Fax:309-693-9385
Practice Address - Street 1:6339 N BIG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2908
Practice Address - Country:US
Practice Address - Phone:309-693-3315
Practice Address - Fax:309-693-9385
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD15916Medicare UPIN