MEDICARE: LESLIE SHOCK

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	2086S0122X	Plastic and Reconstructive Surgery Physician	2016017558	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1053046888	OTHER		ORGANIZATION NPI

General Provider Information

NPI Number	:	1649628439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE SHOCK

Provider Business Mailing Address
First Line	:	3220 BLUFF CREEK DR
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-3663
Country	:	US
Telephone Number	:	573-224-8200
Fax Number	:

Provider Business Practice Location Address
First Line	:	3220 BLUFF CREEK DR
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-3663
Country	:	US
Telephone Number	:	573-224-8200
Fax Number	:

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

Provider Enumeration Date	:	06/02/2016
Last Update Date	:	04/03/2023

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Directions to “ LESLIE SHOCK ” Practice Location

Language	Start Address	Practice Location

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