Provider Demographics
NPI:1851598320
Name:LANDIS, LESLEY VAUGHN (MD)
Entity Type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:VAUGHN
Last Name:LANDIS
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 1:2005 E 21ST ST STE 350
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-1403
Mailing Address - Country:US
Mailing Address - Phone:918-764-8516
Mailing Address - Fax:918-764-8514
Practice Address - Street 1:2005 E 21ST ST STE 350
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-1403
Practice Address - Country:US
Practice Address - Phone:918-764-8516
Practice Address - Fax:918-764-8514
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25842208600000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200173290AMedicaid
OKOKA100554Medicare PIN