Provider Demographics
NPI:1528017282
Name:BEAR, LESLIE HART (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:HART
Last Name:BEAR
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 1:1815 HOSPITAL DR
Mailing Address - Street 2:# 462
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204
Mailing Address - Country:US
Mailing Address - Phone:601-373-0594
Mailing Address - Fax:601-372-9443
Practice Address - Street 1:1815 HOSPITAL DR
Practice Address - Street 2:# 462
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204
Practice Address - Country:US
Practice Address - Phone:601-373-0594
Practice Address - Fax:601-372-9443
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06156207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00019404Medicaid
MS181948425Medicare ID - Type Unspecified
MSD00850Medicare UPIN