Provider Demographics
NPI:1831171115
Name:KIRK, LESLIE G (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:G
Last Name:KIRK
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 1:3945 E PARADISE FALLS DR
Mailing Address - Street 2:STE 201
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6683
Mailing Address - Country:US
Mailing Address - Phone:520-290-5888
Mailing Address - Fax:520-290-5551
Practice Address - Street 1:3945 E PARADISE FALLS DR
Practice Address - Street 2:STE 201
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6683
Practice Address - Country:US
Practice Address - Phone:520-290-5888
Practice Address - Fax:520-290-5551
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5351207R00000X
AZ05351207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ201640Medicaid
AZ201640Medicaid
AZZ130952Medicare PIN