Healthcare Provider Details

I. General information

NPI: 1700044963
Provider Name (Legal Business Name): LESLIE BLAIRE PARENT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLIE B. PETERSOHN M.D.

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 11/27/2023
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E COUNTY LINE RD SUITE B
GREENWOOD IN
46143-1079
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-497-6333
  • Fax: 317-497-6334
Mailing address:
  • Phone: 317-497-6330
  • Fax: 317-497-6334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01068521
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: