Healthcare Provider Details

I. General information

NPI: 1760973515
Provider Name (Legal Business Name): LESLIE SMEBAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2018
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 LAKE ST
OAK PARK IL
60302-2606
US

IV. Provider business mailing address

14 LAKE ST
OAK PARK IL
60302-2606
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 708-383-0113
  • Fax: 708-383-9911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.157901
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: