Healthcare Provider Details

I. General information

NPI: 1700105780
Provider Name (Legal Business Name): LESLIE MARIE GREENLEE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2010
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 A AVE NE
CEDAR RAPIDS IA
52402-5057
US

IV. Provider business mailing address

855 A AVE NE
CEDAR RAPIDS IA
52402-5057
US

V. Phone/Fax

Practice location:
  • Phone: 319-368-9301
  • Fax:
Mailing address:
  • Phone: 319-431-8011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4417
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1700105780
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: