Provider Demographics
NPI:1922174630
Name:LESLIE, JAMES EDWARD (PT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDWARD
Last Name:LESLIE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:260-432-4700
Mailing Address - Fax:260-459-9262
Practice Address - Street 1:1220 A N WAYNE ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703
Practice Address - Country:US
Practice Address - Phone:260-624-2288
Practice Address - Fax:260-624-2286
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006595A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000197328OtherANTHEM BCBS
IN200362940AMedicaid
IN4423623OtherAETNA
IN35179001202OtherCARESOURCE
IN1424OtherPHP
IN156546Medicare ID - Type Unspecified