Provider Demographics
NPI:1700812963
Name:PO, LESLEY L (MD)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:L
Last Name:PO
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 1:130 W ROUTE 66 STE 208
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6251
Mailing Address - Country:US
Mailing Address - Phone:626-335-4079
Mailing Address - Fax:626-335-5507
Practice Address - Street 1:130 W ROUTE 66
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6249
Practice Address - Country:US
Practice Address - Phone:626-335-4079
Practice Address - Fax:626-335-5507
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01272681/DU4034OtherRAILROAD MEDICARE
CA00A709110Medicaid
00A709110OtherMEDI-CAL
CAWA70911BMedicare PIN
CAAV667ZMedicare PIN
CAAV667XMedicare PIN
CAAV667WMedicare PIN
CAAV667YMedicare PIN
CAP01272681/DU4034OtherRAILROAD MEDICARE
CABI451ZMedicare PIN