Basic Information
| Provider Information | |||||||||
| NPI: | 1902007883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | SPENCER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5333 MCAULEY DR | ||||||||
| Address2: | SUITE 6016 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347128350 | ||||||||
| FaxNumber: | 7347128351 | ||||||||
| Practice Location | |||||||||
| Address1: | 5333 MCAULEY DR RM 6016 | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347128350 | ||||||||
| FaxNumber: | 7347128351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 41550 | AZ | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 4301082185 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 424851 | 05 | AZ | MEDICAID |