Basic Information
| Provider Information | |||||||||
| NPI: | 1265405534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLISON | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5080 SPECTRUM DR | ||||||||
| Address2: | STE 1200W | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750014624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727207820 | ||||||||
| FaxNumber: | 2147754502 | ||||||||
| Practice Location | |||||||||
| Address1: | 6920 INDIANAPOLIS BLVD | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463242206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197638112 | ||||||||
| FaxNumber: | 2197643251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 03/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | J7408 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 111937204 | 05 | TX | MEDICAID | 111937202 | 01 | TX | MEDICAID | OTHER | 01072872A | 01 | IN | STATE LICENSE | OTHER | 164204301 | 05 | TX | MEDICAID | 4119831 | 01 | TX | BLUE LINK # | OTHER | 00U53H | 01 | BLUE CROSS BLUE SHIELD | OTHER | 21643 | 01 | TX | UTMB | OTHER | 5272075 | 01 | TX | AETNA | OTHER | 429053 | 01 | WELLCARE | OTHER | 121372 | 01 | TX | SUPERIOR HEALTH | OTHER |