Provider Demographics
NPI:1831198209
Name:DERDEYN, LESLIE JOHN (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:JOHN
Last Name:DERDEYN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:LESLIE
Other - Last Name:DERDEYN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:13737 NOEL RD STE 1600
Mailing Address - Street 2:ATTN RAYS
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1374
Mailing Address - Country:US
Mailing Address - Phone:303-933-8270
Mailing Address - Fax:303-933-8270
Practice Address - Street 1:13737 NOEL RD STE 1600
Practice Address - Street 2:ATTN RAYS
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-1374
Practice Address - Country:US
Practice Address - Phone:303-933-8270
Practice Address - Fax:303-933-8270
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF39002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132261203Medicaid
B22220Medicare UPIN
TX132261203Medicaid