Provider Demographics
NPI:1265429583
Name:CLARK-LOESER, LESLEY (MD)
Entity type:Individual
Prefix:DR
First Name:LESLEY
Middle Name:
Last Name:CLARK-LOESER
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 1:3501 S UNIVERSITY DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2001
Mailing Address - Country:US
Mailing Address - Phone:954-998-0345
Mailing Address - Fax:954-998-0344
Practice Address - Street 1:3501 S UNIVERSITY DR
Practice Address - Street 2:SUITE 5
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2001
Practice Address - Country:US
Practice Address - Phone:954-998-0345
Practice Address - Fax:954-998-0344
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92842174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28636OtherBC & BS OF FLORIDA
FLI38983Medicare UPIN
FLU5550YMedicare PIN