Provider Demographics
NPI:1639240732
Name:HEDDLESTON, LESLIE N (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:N
Last Name:HEDDLESTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 86370
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6370
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:
Practice Address - Street 1:1417 S CLIFF AVE
Practice Address - Street 2:STE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1063
Practice Address - Country:US
Practice Address - Phone:605-322-8937
Practice Address - Fax:605-322-8938
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3758207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1639240732OtherARAZ/AMERICA'S PPO
SD283761009502OtherPREFERRED ONE
MN774219300Medicaid
SDHP30795OtherHEALTHPARTNERS
IA1639240732Medicaid
SD1658OtherMIDLANDS CHOICE
SD3758OtherSD STATE LICENSE
CAG54151OtherCALIFORNIA STATE LICENSE
SD6200053Medicaid
NE10025040700Medicaid
SD3758OtherDAKOTACARE
SD4993265OtherBLUE CROSS
SD370624200OtherDEPT OF LABOR
SD57105AD06OtherWPS TRICARE
MN658C9HEOtherBLUE CROSS
MN658C9HEOtherCC SYSTEMS/ BLUE PLUS
MN924114229808OtherPRIMEWEST
SD1639240732OtherMEDICA
SD1639240732OtherARAZ/AMERICA'S PPO
SD1658OtherMIDLANDS CHOICE