Provider Demographics
NPI:1205320579
Name:RAINBOLT, LESLIE (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:RAINBOLT
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 1:6821 NW GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-5413
Mailing Address - Country:US
Mailing Address - Phone:405-821-4112
Mailing Address - Fax:
Practice Address - Street 1:6821 NW GRAND BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-5413
Practice Address - Country:US
Practice Address - Phone:405-821-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19520207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology