Provider Demographics
NPI:1598783326
Name:STANWIX, LESLIE A (DO)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:STANWIX
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 1:1413 N MILDRED RD
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1413 N MILDRED RD
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2258
Practice Address - Country:US
Practice Address - Phone:970-564-1037
Practice Address - Fax:970-564-1041
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01234228Medicaid
D24272Medicare UPIN
CO01234228Medicaid