Basic Information
| Provider Information | |||||||||
| NPI: | 1588741755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LESLIE | ||||||||
| FirstName: | DARRELL | ||||||||
| MiddleName: | BLAKE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE | ||||||||
| Address2: | 5TH FLOOR MERCY PHO/CVO | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192519830 | ||||||||
| FaxNumber: | 4192511826 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704414568 | ||||||||
| FaxNumber: | 2704414288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 06/22/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 41553 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100040160 | 05 | KY | MEDICAID |