Provider Demographics
NPI:1760619308
Name:CHARLES, LESLIE A (IDMT)
Entity Type:Individual
Prefix:MISS
First Name:LESLIE
Middle Name:A
Last Name:CHARLES
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 MDOS/SGOPF
Mailing Address - Street 2:BLDG 777 UNIT 2060
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96278-2060
Mailing Address - Country:US
Mailing Address - Phone:82010-661-2500
Mailing Address - Fax:
Practice Address - Street 1:51 MDOS/SGOPF
Practice Address - Street 2:BLDG 777 UNIT 2060
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96278-2060
Practice Address - Country:US
Practice Address - Phone:82010-661-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians