Provider Demographics
NPI:1689662306
Name:RILEY, LESLIE A (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:RILEY
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 1:3 LIONS DR
Mailing Address - Street 2:FAMILY CARE CENTER NORTH LIBERTY
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-9575
Mailing Address - Country:US
Mailing Address - Phone:319-626-5680
Mailing Address - Fax:319-626-5687
Practice Address - Street 1:3 LIONS DR
Practice Address - Street 2:FAMILY CARE CENTER NORTH LIBERTY
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-9575
Practice Address - Country:US
Practice Address - Phone:319-626-5680
Practice Address - Fax:319-626-5687
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28162207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3154245Medicaid
IAI1422Medicare PIN
F06877Medicare UPIN