Provider Demographics
NPI:1619193158
Name:PROCTOR, LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:PROCTOR
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 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:303-338-4545
Mailing Address - Fax:
Practice Address - Street 1:1375 E 19TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1114
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-00842207R00000X
CO48561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO020671OtherKAISER COMMERCIAL NUMBER
CO02174260Medicaid
CO020671OtherKAISER COMMERCIAL NUMBER