Provider Demographics
NPI:1417039454
Name:LESLIE, CLARK J (MD)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:J
Last Name:LESLIE
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 1:100 CLARK CT
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-9395
Mailing Address - Country:US
Mailing Address - Phone:740-432-5685
Mailing Address - Fax:740-432-3812
Practice Address - Street 1:100 CLARK CT
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-9395
Practice Address - Country:US
Practice Address - Phone:740-432-5685
Practice Address - Fax:740-432-3812
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072500208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2023330Medicaid
OHG55515Medicare UPIN
OH2023330Medicaid