Provider Demographics
NPI:1578517504
Name:LISDELL, LESLIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:L
Last Name:LISDELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LESLIE
Other - Middle Name:LEE
Other - Last Name:LISDELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:112 NORTH 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:OKEMAH
Mailing Address - State:OK
Mailing Address - Zip Code:74859-2602
Mailing Address - Country:US
Mailing Address - Phone:918-623-3060
Mailing Address - Fax:918-623-2380
Practice Address - Street 1:112 NORTH 3RD STREET
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-2602
Practice Address - Country:US
Practice Address - Phone:405-382-4939
Practice Address - Fax:405-382-4947
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24484207Q00000X
ARE-5170207Q00000X
TXJ8643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine