Basic Information
| Provider Information | |||||||||
| NPI: | 1316912462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | LESLIE | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1601 PARKVIEW AVE | ||||||||
| Address2: | CREDENTIALING S200 | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611071822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153955861 | ||||||||
| FaxNumber: | 8153955575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 N BLACKHAWK BLVD | ||||||||
| Address2: | UNIV PRIMARY CARE CLINIC @ ROCKTON | ||||||||
| City: | ROCKTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610721513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156242644 | ||||||||
| FaxNumber: | 8156242186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036090988 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BD4739186 | 01 | IL | DEA | OTHER | 036090988 | 01 | IL | STATE LICENSE | OTHER | 336052592 | 01 | IL | CONTROLLED SUBSTANCE | OTHER |