Provider Demographics
NPI:1396188975
Name:FITZGERALD, LESLIE M (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:M
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 N STATE OF FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6056
Mailing Address - Country:US
Mailing Address - Phone:423-439-6283
Mailing Address - Fax:
Practice Address - Street 1:1225 E WEISGARBER RD STE 200
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909
Practice Address - Country:US
Practice Address - Phone:186-558-4474
Practice Address - Fax:865-584-1363
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN53803207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ031939Medicaid