Provider Demographics
NPI:1487675161
Name:MATHERS, LESLIE III (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MATHERS
Suffix:III
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 1:602 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2530
Mailing Address - Country:US
Mailing Address - Phone:217-383-3311
Mailing Address - Fax:
Practice Address - Street 1:1701 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2101
Practice Address - Country:US
Practice Address - Phone:309-664-3038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360552602083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2613OtherMEDICARE GROUP PTAN
ILD93400Medicare UPIN
ILIL2613025Medicare PIN