Healthcare Provider Details

I. General information

NPI: 1780604751
Provider Name (Legal Business Name): LESLIE A RICHARDSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-3712
  • Fax: 910-450-3766
Mailing address:
  • Phone: 910-450-4127
  • Fax: 910-450-3766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number95-00703
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number95-00703
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: