Provider Demographics
NPI:1720029895
Name:WILSON, LESLIE DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:DEAN
Last Name:WILSON
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 1:2621 MITCHAM DR
Mailing Address - Street 2:UNIT 103
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5480
Mailing Address - Country:US
Mailing Address - Phone:850-219-2273
Mailing Address - Fax:850-201-2410
Practice Address - Street 1:2621 MITCHAM DR
Practice Address - Street 2:UNIT 103
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5480
Practice Address - Country:US
Practice Address - Phone:850-219-2273
Practice Address - Fax:850-201-2410
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0057097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0911XOtherBLUE CROSS BLUE SHIELD
FL743041128OtherUNITED HEALTH CARE
FL0911XOtherBLUE CROSS BLUE SHIELD
FL09911XMedicare ID - Type Unspecified