Provider Demographics
NPI:1962489229
Name:FULLER, LESLIE E (DO)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:E
Last Name:FULLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:81602-0932
Mailing Address - Country:US
Mailing Address - Phone:970-945-1443
Mailing Address - Fax:
Practice Address - Street 1:1906 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4227
Practice Address - Country:US
Practice Address - Phone:970-945-6535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32980207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FU12322OtherBLUE CROSS
CO01329804Medicaid
FU12322OtherBLUE CROSS
F84767Medicare UPIN