MEDICARE: LESLIE RAINBOLT 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	207N00000X	Dermatology Physician	19520	OK

General Provider Information

NPI Number	:	1205320579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE RAINBOLT MD

Provider Business Mailing Address
First Line	:	6821 NW GRAND BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-5413
Country	:	US
Telephone Number	:	405-821-4112
Fax Number	:

Provider Business Practice Location Address
First Line	:	6821 NW GRAND BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-5413
Country	:	US
Telephone Number	:	405-821-4112
Fax Number	:

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

Provider Enumeration Date	:	06/19/2018
Last Update Date	:	06/19/2018

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Directions to “ LESLIE RAINBOLT MD” Practice Location

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