Provider Demographics
NPI:1386918621
Name:DR. LESLY JEAN MD PA
Entity type:Organization
Organization Name:DR. LESLY JEAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHILANA
Authorized Official - Middle Name:ROBINSON
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-781-3122
Mailing Address - Street 1:321 W ATLANTIC BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-6048
Mailing Address - Country:US
Mailing Address - Phone:954-781-3122
Mailing Address - Fax:954-781-0860
Practice Address - Street 1:321 W ATLANTIC BLVD
Practice Address - Street 2:STE 102
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-6048
Practice Address - Country:US
Practice Address - Phone:954-781-3122
Practice Address - Fax:954-781-0860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL45032207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061521800Medicaid
FL07927OtherMEDICARE I.D.
FL061521800Medicaid