Healthcare Provider Details

I. General information

NPI: 1548291107
Provider Name (Legal Business Name): LESLY DESROULEAUX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38754 STATE ROAD 80
BELLE GLADE FL
33430-5615
US

IV. Provider business mailing address

38754 STATE ROAD 80
BELLE GLADE FL
33430-5615
US

V. Phone/Fax

Practice location:
  • Phone: 561-996-1600
  • Fax: 561-837-5332
Mailing address:
  • Phone: 561-996-1600
  • Fax: 561-837-5332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME59527
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: