Healthcare Provider Details
I. General information
NPI: 1639240732
Provider Name (Legal Business Name): LESLIE N. HEDDLESTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 11/11/2006
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
1417 S CLIFF AVE STE 100
SIOUX FALLS SD
57105-1063
US
IV. Provider business mailing address
PO BOX 86370
SIOUX FALLS SD
57118-6370
US
V. Phone/Fax
- Phone: 605-322-8937
- Fax: 605-322-8938
- Phone: 605-322-7510
- Fax:
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 207VM0101X |
| Taxonomy | Maternal & Fetal Medicine Physician |
| License Number | 3758 |
| License Number State | SD |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 1639240732 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | ARAZ/AMERICA'S PPO |
| # 2 | |
| Identifier | 283761009502 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | PREFERRED ONE |
| # 3 | |
| Identifier | 774219300 |
| Identifier Type | MEDICAID |
| Identifier State | MN |
| Identifier Issuer | |
| # 4 | |
| Identifier | HP30795 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | HEALTHPARTNERS |
| # 5 | |
| Identifier | 1639240732 |
| Identifier Type | MEDICAID |
| Identifier State | IA |
| Identifier Issuer | |
| # 6 | |
| Identifier | 1658 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | MIDLANDS CHOICE |
| # 7 | |
| Identifier | 3758 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | SD STATE LICENSE |
| # 8 | |
| Identifier | G54151 |
| Identifier Type | OTHER |
| Identifier State | CA |
| Identifier Issuer | CALIFORNIA STATE LICENSE |
| # 9 | |
| Identifier | 6200053 |
| Identifier Type | MEDICAID |
| Identifier State | SD |
| Identifier Issuer | |
| # 10 | |
| Identifier | 10025040700 |
| Identifier Type | MEDICAID |
| Identifier State | NE |
| Identifier Issuer | |
| # 11 | |
| Identifier | 3758 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | DAKOTACARE |
| # 12 | |
| Identifier | 4993265 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | BLUE CROSS |
| # 13 | |
| Identifier | 370624200 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | DEPT OF LABOR |
| # 14 | |
| Identifier | 57105AD06 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | WPS TRICARE |
| # 15 | |
| Identifier | 658C9HE |
| Identifier Type | OTHER |
| Identifier State | MN |
| Identifier Issuer | BLUE CROSS |
| # 16 | |
| Identifier | 658C9HE |
| Identifier Type | OTHER |
| Identifier State | MN |
| Identifier Issuer | CC SYSTEMS/ BLUE PLUS |
| # 17 | |
| Identifier | 924114229808 |
| Identifier Type | OTHER |
| Identifier State | MN |
| Identifier Issuer | PRIMEWEST |
| # 18 | |
| Identifier | 1639240732 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | MEDICA |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
