Provider Demographics
NPI:1871677799
Name:PICKENS, LESLIE R (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:R
Last Name:PICKENS
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 1:8804 SURREY CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22309-2243
Mailing Address - Country:US
Mailing Address - Phone:703-329-1037
Mailing Address - Fax:703-329-4595
Practice Address - Street 1:6020 RICHMOND HWY STE 100
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22303-2157
Practice Address - Country:US
Practice Address - Phone:703-329-1037
Practice Address - Fax:703-329-4595
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046241207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA482920Medicare ID - Type UnspecifiedMEDICARE ID#