Provider Demographics
NPI:1891809505
Name:BISHOP, LESLIE M (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:BISHOP
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 1:4300 SPEEDWAY, #4918
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751
Mailing Address - Country:US
Mailing Address - Phone:512-275-3700
Mailing Address - Fax:
Practice Address - Street 1:3070 COLLEGE ST, #406
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701
Practice Address - Country:US
Practice Address - Phone:512-275-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ39932081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0099AFMedicare PIN