Provider Demographics
NPI:1689663387
Name:COUCH, LESLIE ANN (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:COUCH
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:PO BOX 731912
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-1912
Mailing Address - Country:US
Mailing Address - Phone:903-877-7777
Mailing Address - Fax:903-877-5838
Practice Address - Street 1:11937 US HIGHWAY 271
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75708-3154
Practice Address - Country:US
Practice Address - Phone:903-877-7777
Practice Address - Fax:903-877-5838
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4935207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103858001Medicaid
TX103858001Medicaid
TX83M526Medicare ID - Type Unspecified