Provider Demographics
NPI:1518240456
Name:WAGENBERG-GRELLA, LESLIE A (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:WAGENBERG-GRELLA
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 1:120 MEDICAL BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-0220
Mailing Address - Country:US
Mailing Address - Phone:352-684-1340
Mailing Address - Fax:
Practice Address - Street 1:120 MEDICAL BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-0220
Practice Address - Country:US
Practice Address - Phone:352-684-1340
Practice Address - Fax:352-684-0694
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 110500208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006606100Medicaid