Provider Demographics
NPI:1619170602
Name:SMOAK, LESLIE DEANNA (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:DEANNA
Last Name:SMOAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 GLYNN STREET SOUTH
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:770-461-4126
Mailing Address - Fax:
Practice Address - Street 1:619 19TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35249-1900
Practice Address - Country:US
Practice Address - Phone:205-934-5038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64277208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program