Provider Demographics
NPI:1508854324
Name:TAYLOR, LESLI A (MD)
Entity Type:Individual
Prefix:
First Name:LESLI
Middle Name:A
Last Name:TAYLOR
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-439-7201
Mailing Address - Fax:423-439-7219
Practice Address - Street 1:325 N STATE OF FRANKLIN RD
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6056
Practice Address - Country:US
Practice Address - Phone:423-439-7201
Practice Address - Fax:423-439-7219
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD401662086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B95341Medicare UPIN
TN333312Medicare ID - Type Unspecified