Provider Demographics
NPI:1194782268
Name:LESLIE, JONATHAN B (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:B
Last Name:LESLIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:JONATHAN
Other - Middle Name:B
Other - Last Name:LESLIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:21110 BISCAYNE BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1252
Mailing Address - Country:US
Mailing Address - Phone:305-932-0024
Mailing Address - Fax:305-682-8430
Practice Address - Street 1:21110 BISCAYNE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1252
Practice Address - Country:US
Practice Address - Phone:305-932-0024
Practice Address - Fax:305-682-8430
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS3804207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066504500Medicaid
FL82427Medicare ID - Type UnspecifiedMEDICARE PROVIDER
FLD60635Medicare UPIN