Provider Demographics
NPI:1619926664
Name:LESLIE, DEAN F (MD)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:F
Last Name:LESLIE
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 1:3050 MONTVALE DR STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6924
Mailing Address - Country:US
Mailing Address - Phone:217-726-8096
Mailing Address - Fax:
Practice Address - Street 1:3050 MONTVALE DR STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704
Practice Address - Country:US
Practice Address - Phone:217-726-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180320712085R0202X
MN363452085R0202X
WI811492085R0202X
KY330312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64330319Medicaid
IN200103160Medicaid
FL9097732-00Medicaid
KY000000062492OtherANTHEM BLUE FACET
TX060795401Medicaid
KY1055713Medicaid
OH2136898Medicaid
CA00G820990Medicaid