Provider Demographics
NPI:1255408878
Name:MCCLELLAN, LESLIE C (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:C
Last Name:MCCLELLAN
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 1:1033 MELODY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1547
Mailing Address - Country:US
Mailing Address - Phone:847-828-1400
Mailing Address - Fax:
Practice Address - Street 1:250 CENTER DR
Practice Address - Street 2:STE 201
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1582
Practice Address - Country:US
Practice Address - Phone:847-549-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084851208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084851 1Medicaid
G71232Medicare UPIN
IL036084851 1Medicaid
IL510420 K18795Medicare ID - Type Unspecified