Healthcare Provider Details

I. General information

NPI: 1437342433
Provider Name (Legal Business Name): CLASINA LESLIE SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4753 N BROADWAY ST SUITE 910
CHICAGO IL
60640-5266
US

IV. Provider business mailing address

5312 N WINTHROP AVE APT 1N
CHICAGO IL
60640-2389
US

V. Phone/Fax

Practice location:
  • Phone: 773-609-3520
  • Fax:
Mailing address:
  • Phone: 773-350-2725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA118378
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.124367
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036.124367
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: