Provider Demographics
NPI:1578562849
Name:SALLOUM, LESLIE JOHN (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:JOHN
Last Name:SALLOUM
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 LAUCHWOOD DR
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-5501
Practice Address - Country:US
Practice Address - Phone:910-277-9164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301519208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1578562849Medicaid
NC8913506Medicaid
FH2030155OtherFCC
SCN01510Medicaid
NC151XNOtherBCBS
NC2026338BMedicare PIN
NC151XNOtherBCBS
E55065Medicare UPIN
NC8913506Medicaid
NCNC3100AMedicare PIN