Provider Demographics
NPI:1891375515
Name:EMMANUEL, MARIE-LESLY (MD)
Entity type:Individual
Prefix:DR
First Name:MARIE-LESLY
Middle Name:
Last Name:EMMANUEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIE-LESLY
Other - Middle Name:
Other - Last Name:EMMANUEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1889 W WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-9709
Mailing Address - Country:US
Mailing Address - Phone:224-308-4614
Mailing Address - Fax:
Practice Address - Street 1:2490 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAKE STATION
Practice Address - State:IN
Practice Address - Zip Code:46405-2122
Practice Address - Country:US
Practice Address - Phone:210-358-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01094805A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine