Provider Demographics
NPI:1336249630
Name:SMITH, LESLIE WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
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:PO BOX 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-735-2400
Mailing Address - Fax:817-735-0615
Practice Address - Street 1:855 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-735-2400
Practice Address - Fax:817-735-0615
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2090982084P0800X, 2084P0802X
CT0238292084P0800X, 2084P0802X
TXF20202084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001238294Medicaid
TXP00998014OtherRAILROAD MEDICARE
TX204374701Medicaid
TX8X5119OtherBCBS
CT001238294Medicaid
CTD41126Medicare UPIN
TX8X5119OtherBCBS