Healthcare Provider Details

I. General information

NPI: 1801834056
Provider Name (Legal Business Name): LESLIE B WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 COUCH AVE
KIRKWOOD MO
63122-5536
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY ATTENTION: CREDENTIALING DEPARTMENT
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-1500
  • Fax: 314-966-1681
Mailing address:
  • Phone: 314-989-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number110704
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number110704
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number110704
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: