Provider Demographics
NPI:1457348120
Name:WILKERSON, LESLIE ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ANDREW
Last Name:WILKERSON
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 1:2406 LIGHTHOUSE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-7401
Mailing Address - Country:US
Mailing Address - Phone:770-534-3616
Mailing Address - Fax:770-287-3477
Practice Address - Street 1:2406 LIGHTHOUSE MANOR DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-7401
Practice Address - Country:US
Practice Address - Phone:770-534-3616
Practice Address - Fax:770-287-3477
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022491207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00217544AMedicaid
GA732949OtherBLUE CROSS/BLUE SHIELD
GAE91228Medicare UPIN
GA00217544AMedicaid