Basic Information
| Provider Information | |||||||||
| NPI: | 1962751529 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRED L. LESLIE, DO., P.L. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10875 PARK BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SEMINOLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337725456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278519910 | ||||||||
| FaxNumber: | 7278519949 | ||||||||
| Practice Location | |||||||||
| Address1: | 10875 PARK BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SEMINOLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337725456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278519910 | ||||||||
| FaxNumber: | 7278519949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 10/04/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LESLIE | ||||||||
| AuthorizedOfficialFirstName: | FRED | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7278519910 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS3678 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.