Provider Demographics
NPI:1346264702
Name:COWN, LESLEY JILL (MD, LLC)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:JILL
Last Name:COWN
Suffix:
Gender:F
Credentials:MD, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4061 VINEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-5039
Mailing Address - Country:US
Mailing Address - Phone:478-757-7345
Mailing Address - Fax:478-757-4911
Practice Address - Street 1:4061 VINEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5039
Practice Address - Country:US
Practice Address - Phone:478-757-7345
Practice Address - Fax:478-757-4911
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00518559JMedicaid
GA00518559JMedicaid
GA11BDTKTMedicare ID - Type Unspecified