Provider Demographics
NPI:1376564492
Name:CHARLES, LESLEY ALTHEA (MD)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:ALTHEA
Last Name:CHARLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:711 S ASHLAND AVE
Mailing Address - Street 2:UNIT N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3166
Mailing Address - Country:US
Mailing Address - Phone:312-226-2665
Mailing Address - Fax:312-226-2665
Practice Address - Street 1:500 E 51ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-2400
Practice Address - Country:US
Practice Address - Phone:312-572-2657
Practice Address - Fax:312-572-2595
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-082544207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-082544OtherSTATE LICENSE NUMBER