Provider Demographics
NPI:1346773348
Name:JOSEPH, LESLIE (DPM)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-2100
Mailing Address - Country:US
Mailing Address - Phone:248-808-6012
Mailing Address - Fax:248-808-6056
Practice Address - Street 1:12303 DEPAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2727
Practice Address - Country:US
Practice Address - Phone:314-344-7545
Practice Address - Fax:314-344-7258
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5901400370213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program