Provider Demographics
NPI:1902836513
Name:LESLIE, JOHN G (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:LESLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 NIZHONI BLVD
Mailing Address - Street 2:BOX 1337
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5748
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1310
Practice Address - Street 1:516 NIZHONI BLVD
Practice Address - Street 2:BOX 1337
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1310
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM9396207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000S6962Medicaid
AZ414566Medicaid
TX9HZ028Medicare ID - Type UnspecifiedHSZ002
TX8HZ270Medicare ID - Type UnspecifiedHSZ005
TX8HZL31Medicare ID - Type UnspecifiedHSZ003
F58709Medicare UPIN
TX8HZ148Medicare ID - Type UnspecifiedHSZ006
TX8HBX40Medicare ID - Type UnspecifiedHSZ197
TX8HZ136Medicare ID - Type UnspecifiedHSZ001