Provider Demographics
NPI:1366479032
Name:LESLIE, STEPHEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:A
Last Name:LESLIE
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 1:1900 CENTRACARE CIRCLE
Mailing Address - Street 2:CENTRACARE CLINIC- WOMEN'S & CHILDRENS
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-654-3650
Mailing Address - Fax:
Practice Address - Street 1:1900 CENTRACARE CIRCLE
Practice Address - Street 2:CENTRACARE CLINIC- WOMEN'S & CHILDRENS
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-654-3630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51744207K00000X
MN104220207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0215590Medicaid
C50298Medicare UPIN
IAC50298Medicare UPIN
IA20740Medicare PIN