Provider Demographics
NPI:1316406218
Name:DE LOS SANTOS, LESLIE MARICE (DO)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:MARICE
Last Name:DE LOS SANTOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:MARICE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1500 UNIVERSITY DR E STE 100
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-2600
Mailing Address - Country:US
Mailing Address - Phone:979-383-2358
Mailing Address - Fax:
Practice Address - Street 1:1602 ROCK PRAIRIE RD STE 300
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8309
Practice Address - Country:US
Practice Address - Phone:979-693-7400
Practice Address - Fax:979-693-2845
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT4333207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine