Basic Information
| Provider Information | |||||||||
| NPI: | 1982696183 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LESESNE | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1409 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287161409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286272211 | ||||||||
| FaxNumber: | 8286272216 | ||||||||
| Practice Location | |||||||||
| Address1: | 6750 CAROLINA BLVD | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287217052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286272211 | ||||||||
| FaxNumber: | 8286272216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16410 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8951748 | 05 | NC | MEDICAID |