Provider Demographics
NPI:1922325612
Name:REILLY, LESLIE K (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:K
Last Name:REILLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 DAUPHINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70116-1926
Mailing Address - Country:US
Mailing Address - Phone:501-658-4419
Mailing Address - Fax:
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5720
Practice Address - Country:US
Practice Address - Phone:504-896-2143
Practice Address - Fax:504-896-2720
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2013-01632208000000X, 208M00000X
LAMD.207234208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1177130Medicaid
NC1922325612Medicaid
SCNC1850Medicaid
NC1922325612Medicaid