Provider Demographics
NPI:1366858086
Name:NIFONG, LESLIE WILEY (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:WILEY
Last Name:NIFONG
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:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 HEART DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-8982
Practice Address - Country:US
Practice Address - Phone:252-744-2187
Practice Address - Fax:252-744-3542
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98-00988174400000X
NC9800988208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1366858086Medicaid
NC1897FOtherBCBS NC
NC1366858086Medicaid