Provider Demographics
NPI:1316912462
Name:DEAN, LESLIE A (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:A
Last Name:DEAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 PARKVIEW AVE
Mailing Address - Street 2:CREDENTIALING S200
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1822
Mailing Address - Country:US
Mailing Address - Phone:815-395-5861
Mailing Address - Fax:815-395-5575
Practice Address - Street 1:1511 N BLACKHAWK BLVD
Practice Address - Street 2:UNIV PRIMARY CARE CLINIC @ ROCKTON
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-1513
Practice Address - Country:US
Practice Address - Phone:815-624-2644
Practice Address - Fax:815-624-2186
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090988OtherSTATE LICENSE
IL336052592OtherCONTROLLED SUBSTANCE
IL336052592OtherCONTROLLED SUBSTANCE
ILG32700Medicare UPIN