Provider Demographics
NPI:1760407258
Name:HARRIS, LESLEY A (MD)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:A
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:ANN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-969-6552
Mailing Address - Fax:502-212-1358
Practice Address - Street 1:12615 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-4452
Practice Address - Country:US
Practice Address - Phone:502-261-1595
Practice Address - Fax:502-261-1590
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40032208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000486608OtherANTHEM FOR NCMA TYLER
IN200865590Medicaid
KY284510500OtherPAD NMCA TYLER
KY64125339Medicaid
KYP00388569OtherRAILROAD MEDICARE
KY50014893OtherPASSPORT NMCA TYLER
KY64125339Medicaid
KY0998847Medicare PIN