Basic Information
| Provider Information | |||||||||
| NPI: | 1386918621 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR. LESLY JEAN MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 321 W ATLANTIC BLVD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330606048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547813122 | ||||||||
| FaxNumber: | 9547810860 | ||||||||
| Practice Location | |||||||||
| Address1: | 321 W ATLANTIC BLVD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330606048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547813122 | ||||||||
| FaxNumber: | 9547810860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2012 | ||||||||
| LastUpdateDate: | 09/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | PHILANA | ||||||||
| AuthorizedOfficialMiddleName: | ROBINSON | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9547813122 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 45032 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 061521800 | 05 | FL | MEDICAID | 07927 | 01 | FL | MEDICARE I.D. | OTHER |