MEDICARE: LESLIE TILLOTSON WEBSTER III 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	208600000X	Surgery Physician	9900719	NC

General Provider Information

NPI Number	:	1760468771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE TILLOTSON WEBSTER III MD

Provider Business Mailing Address
First Line	:	PO BOX 19305
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28219-9305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10650 PARK RD
Second Line	:	STE 480 A
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-8538
Country	:	US
Telephone Number	:	704-355-1813
Fax Number	:

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

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	07/15/2024

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