Provider Demographics
NPI:1780002717
Name:BENNY, LESLIE JACOB (DO)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:JACOB
Last Name:BENNY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:3263 EATON RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6830
Practice Address - Country:US
Practice Address - Phone:920-433-6700
Practice Address - Fax:920-433-6719
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1729207RR0500X
390200000X
WI23400-875207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program