Provider Demographics
NPI:1699761700
Name:MCQUISTON, LESLIE T (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:T
Last Name:MCQUISTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:D
Other - Last Name:TACKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1301 BARBARA JORDAN BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3077
Mailing Address - Country:US
Mailing Address - Phone:512-472-6134
Mailing Address - Fax:512-472-2928
Practice Address - Street 1:1301 BARBARA JORDAN BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3077
Practice Address - Country:US
Practice Address - Phone:512-472-6134
Practice Address - Fax:512-472-2928
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM01742088P0231X, 2088P0231X
TXM1074208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DD165OtherBCBS
H42912Medicare UPIN
TXTXB146959Medicare PIN
TX1715476-02Medicaid