Provider Demographics
NPI:1831140359
Name:GARVIN-LESLIE, PENOLA M (MD)
Entity Type:Individual
Prefix:
First Name:PENOLA
Middle Name:M
Last Name:GARVIN-LESLIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 CAMPAU FARMS CIR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-5167
Mailing Address - Country:US
Mailing Address - Phone:313-567-2704
Mailing Address - Fax:313-567-2704
Practice Address - Street 1:1837 CAMPAU FARMS CIR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-5167
Practice Address - Country:US
Practice Address - Phone:313-567-2704
Practice Address - Fax:313-567-2704
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058406207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104757529Medicaid
MIG16200Medicare UPIN
MIG16200Medicare UPIN