Provider Demographics
NPI:1922057009
Name:SHAWN, LESLIE G (DO)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:G
Last Name:SHAWN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 NORTH HIATUS ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026
Mailing Address - Country:US
Mailing Address - Phone:954-442-3434
Mailing Address - Fax:954-441-4425
Practice Address - Street 1:400 NORTH HIATUS ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026
Practice Address - Country:US
Practice Address - Phone:954-442-3434
Practice Address - Fax:954-441-4425
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0003957208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0378046-00Medicaid
82239Medicare ID - Type Unspecified
FL0378046-00Medicaid