Provider Demographics
NPI:1124059639
Name:DOMINGUEZ, LESLIE COPELAND (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:COPELAND
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LESLIE
Other - Middle Name:AUGUSTA
Other - Last Name:COPELAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 54482
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70154-4482
Mailing Address - Country:US
Mailing Address - Phone:985-898-4000
Mailing Address - Fax:985-898-4164
Practice Address - Street 1:1202 S TYLER ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2330
Practice Address - Country:US
Practice Address - Phone:985-898-4000
Practice Address - Fax:985-898-4164
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA26181207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08504875Medicaid
LA1049743Medicaid
LA4F989DL36Medicare PIN
MS08504875Medicaid
LA1049743Medicaid
4F989Medicare PIN