Provider Demographics
NPI:1972671782
Name:NEILSON, LESLIE J (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:J
Last Name:NEILSON
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 1:2386 NW HOYT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3219
Mailing Address - Country:US
Mailing Address - Phone:503-228-5909
Mailing Address - Fax:503-226-4186
Practice Address - Street 1:2386 NW HOYT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3219
Practice Address - Country:US
Practice Address - Phone:503-228-5909
Practice Address - Fax:503-226-4186
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD231412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR111700Medicare ID - Type Unspecified
H06037Medicare UPIN