Provider Demographics
NPI:1750434692
Name:EVERTS, LESLIE E (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:E
Last Name:EVERTS
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 1:1601 CHERRY ST
Mailing Address - Street 2:SUITE 11511
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1320
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:
Practice Address - Street 1:1260 E WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-3969
Practice Address - Country:US
Practice Address - Phone:610-690-4490
Practice Address - Fax:610-328-9391
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD047549L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA014631970Medicaid
PA759432Medicare ID - Type Unspecified
PAF76913Medicare UPIN