MEDICARE: LESLIE WILSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	J7870	TX

General Provider Information

NPI Number	:	1154311108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE WILSON MD

Provider Business Mailing Address
First Line	:	18903 HONEY MESQUITE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-1635
Country	:	US
Telephone Number	:	210-573-8276
Fax Number	:

Provider Business Practice Location Address
First Line	:	3130 SE MILITARY DR STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223-3892
Country	:	US
Telephone Number	:	210-543-7334
Fax Number	:	210-370-3172

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	09/18/2014

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