Healthcare Provider Details

I. General information

NPI: 1154858504
Provider Name (Legal Business Name): DAVID WILLIAM LESKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 10/24/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 FORTUNE BLVD
SHILOH IL
62269-7377
US

IV. Provider business mailing address

12134 TRENTMORE PL
SAINT LOUIS MO
63127-1407
US

V. Phone/Fax

Practice location:
  • Phone: 618-628-0715
  • Fax: 888-371-4468
Mailing address:
  • Phone: 314-330-0952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number36161937
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: