Provider Demographics
NPI:1700826088
Name:NELSON, LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 BOLTON BOONE DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2096
Mailing Address - Country:US
Mailing Address - Phone:469-759-2323
Mailing Address - Fax:469-759-2324
Practice Address - Street 1:2505 BOLTON BOONE DR
Practice Address - Street 2:SUITE 107
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115
Practice Address - Country:US
Practice Address - Phone:469-759-2323
Practice Address - Fax:469-759-2324
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8U1143OtherBLUE CROSS BLUE SHIELD
TXL9825OtherSTATE LICENSES
TX8F1025Medicare ID - Type Unspecified
TX8U1143OtherBLUE CROSS BLUE SHIELD