Provider Demographics
NPI:1710004551
Name:LESLIE WILMOT NELSON MD PA
Entity Type:Organization
Organization Name:LESLIE WILMOT NELSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESILE
Authorized Official - Middle Name:WILMOT
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-548-6648
Mailing Address - Street 1:2803 RIVERSIDE DR
Mailing Address - Street 2:#1905
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-7820
Mailing Address - Country:US
Mailing Address - Phone:817-274-5580
Mailing Address - Fax:817-633-8229
Practice Address - Street 1:909 MEDICAL CENTRE DR
Practice Address - Street 2:STE A
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4757
Practice Address - Country:US
Practice Address - Phone:817-274-5580
Practice Address - Fax:817-274-5540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherFEDERAL TAX ID
TX=========OtherFEDERAL TAX ID