Provider Demographics
NPI:1558519231
Name:WOOD, LESLEY E (DO)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:E
Last Name:WOOD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1112
Mailing Address - Country:US
Mailing Address - Phone:928-515-0632
Mailing Address - Fax:
Practice Address - Street 1:1670 WILLOW CREEK RD STE A
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1112
Practice Address - Country:US
Practice Address - Phone:928-515-0632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60640701207R00000X, 208M00000X
CODR.0054252207R00000X
AZ007403208M00000X
MA237099390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2061364Medicaid