Provider Demographics
NPI:1619187846
Name:VARGHESE, LESLY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:LESLY
Middle Name:THOMAS
Last Name:VARGHESE
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 1:701 CYPRESS ST
Mailing Address - Street 2:P.O.BOX 2509
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5053
Mailing Address - Country:US
Mailing Address - Phone:337-564-2126
Mailing Address - Fax:
Practice Address - Street 1:701 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70664-2509
Practice Address - Country:US
Practice Address - Phone:337-564-2126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.202119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA09236Medicaid