Provider Demographics
NPI:1386626257
Name:LESLIE, KEVIN O (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:O
Last Name:LESLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 42210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85080-2210
Mailing Address - Country:US
Mailing Address - Phone:623-266-7770
Mailing Address - Fax:623-322-4639
Practice Address - Street 1:424 S 56TH ST STE 120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-2108
Practice Address - Country:US
Practice Address - Phone:602-685-5211
Practice Address - Fax:602-685-5325
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23690207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ337768Medicaid
AZ220016822OtherRR MEDICARE
AZ337768Medicaid
AZZ22WCGTB07Medicare PIN