Provider Demographics
NPI:1417023284
Name:SIMONTON-SMITH, LESLIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:L
Last Name:SIMONTON-SMITH
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 1:8 CUSUMANO PROFESSIONAL PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6736
Mailing Address - Country:US
Mailing Address - Phone:618-244-4800
Mailing Address - Fax:618-241-1746
Practice Address - Street 1:8 CUSUMANO PROFESSIONAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6736
Practice Address - Country:US
Practice Address - Phone:618-244-4800
Practice Address - Fax:618-241-1746
Is Sole Proprietor?:No
Enumeration Date:2006-11-25
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069531207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL117129OtherHEALTHLINK
IL4126930OtherBLUE CROSS BLUE SHIELD
IL160050341OtherRAILROAD MEDICARE
IL036069531Medicaid
IL160050341OtherRAILROAD MEDICARE
ILC47908Medicare UPIN