Provider Demographics
NPI:1629362371
Name:CAVAZOS, LESLIE SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:SUSAN
Last Name:CAVAZOS
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 1:3911 AVENUE B STE 2300
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4617
Mailing Address - Country:US
Mailing Address - Phone:308-630-1055
Mailing Address - Fax:308-630-2060
Practice Address - Street 1:3911 AVENUE B STE 2300
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4617
Practice Address - Country:US
Practice Address - Phone:308-630-1055
Practice Address - Fax:308-630-2060
Is Sole Proprietor?:No
Enumeration Date:2011-05-30
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE31869208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation