Healthcare Provider Details

I. General information

NPI: 1578517504
Provider Name (Legal Business Name): LESLIE L LISDELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLIE LEE LISDELL M.D.

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 02/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 NORTH 3RD STREET
OKEMAH OK
74859-2602
US

IV. Provider business mailing address

112 NORTH 3RD STREET
OKEMAH OK
74859-2602
US

V. Phone/Fax

Practice location:
  • Phone: 405-382-4939
  • Fax: 405-382-4947
Mailing address:
  • Phone: 918-623-3060
  • Fax: 918-623-2380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24484
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-5170
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ8643
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: