Provider Demographics
NPI:1548247182
Name:BEADLING, LESLIE BRENT (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:BRENT
Last Name:BEADLING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BRENT
Other - Middle Name:LESLIE
Other - Last Name:BEADLING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11512 LAKE MEAD AVE
Mailing Address - Street 2:BLDG 521
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5835
Mailing Address - Country:US
Mailing Address - Phone:904-807-9747
Mailing Address - Fax:904-807-9746
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:BLDG 521
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5835
Practice Address - Country:US
Practice Address - Phone:904-807-9747
Practice Address - Fax:904-807-9746
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H00522Medicare UPIN
FL44263YMedicare PIN