Provider Demographics
NPI:1598968935
Name:SMITH, LESLIE FEGENBUSH (DO)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:FEGENBUSH
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MISS
Other - First Name:LESLIE
Other - Middle Name:ELAINE
Other - Last Name:FEGENBUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6218
Mailing Address - Country:US
Mailing Address - Phone:502-559-9337
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1318
Practice Address - Country:US
Practice Address - Phone:502-636-7225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03141207P00000X
VA0102202042207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY710066040Medicaid
IN200919590Medicaid