Provider Demographics
NPI:1649201211
Name:KING, LESLIE P (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:P
Last Name:KING
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 1:3636 NE 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2122
Mailing Address - Country:US
Mailing Address - Phone:503-247-8336
Mailing Address - Fax:503-247-8368
Practice Address - Street 1:3636 NE 9TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2122
Practice Address - Country:US
Practice Address - Phone:503-247-8336
Practice Address - Fax:503-247-8368
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20818207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150884Medicaid
OR100384Medicare ID - Type Unspecified
ORG54231Medicare UPIN