Provider Demographics
NPI:1104921402
Name:LU, LESLIE I (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:I
Last Name:LU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26800 CROWN VALLEY PKWY STE 305
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26800 CROWN VALLEY PKWY STE 305
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-364-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033606207R00000X
CAG85467207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA223012OtherLABOR & INDUSTRY
WAP00442323OtherPALMETTO RR MEDICARE
WA1200LUOtherREGENCE
WAMD6063OtherALASKA MEDICAID
WA5891740001OtherDME
WA8204257Medicaid
WAP00442323OtherPALMETTO RR MEDICARE
WA223012OtherLABOR & INDUSTRY