Healthcare Provider Details

I. General information

NPI: 1619926664
Provider Name (Legal Business Name): DEAN F. LESLIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 MONTVALE DR STE A
SPRINGFIELD IL
62704
US

IV. Provider business mailing address

3050 MONTVALE DR STE A
SPRINGFIELD IL
62704-6924
US

V. Phone/Fax

Practice location:
  • Phone: 217-726-8096
  • Fax:
Mailing address:
  • Phone: 217-726-8096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2018032071
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number36345
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number81149
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number33031
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: