Provider Demographics
NPI:1528045069
Name:LONG, LESLE D (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLE
Middle Name:D
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:89A SONIA DR
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-4540
Mailing Address - Country:US
Mailing Address - Phone:864-530-0300
Mailing Address - Fax:864-530-0304
Practice Address - Street 1:89A SONIA DR
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4540
Practice Address - Country:US
Practice Address - Phone:864-530-0300
Practice Address - Fax:864-530-0304
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17555207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC140181Medicaid
SC175553Medicaid
SCG307315834Medicare UPIN
SCG3307316646Medicare UPIN