Provider Demographics
NPI:1891730768
Name:SMOLUCH, LESLIE P (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:P
Last Name:SMOLUCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N 18TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4200
Mailing Address - Country:US
Mailing Address - Phone:541-726-6447
Mailing Address - Fax:541-726-7704
Practice Address - Street 1:1110 N 18TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4200
Practice Address - Country:US
Practice Address - Phone:541-726-6447
Practice Address - Fax:541-726-7704
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10512174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR184465Medicaid
OR184465Medicaid
OR0000BLCDWMedicare ID - Type Unspecified