Provider Demographics
NPI:1992701460
Name:LESLIE, MARK STANTON (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STANTON
Last Name:LESLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W FRONT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2287
Mailing Address - Country:US
Mailing Address - Phone:231-935-0800
Mailing Address - Fax:
Practice Address - Street 1:701 W FRONT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2287
Practice Address - Country:US
Practice Address - Phone:231-935-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044780207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4212833Medicaid
MI0B81023OtherBCBSM
5654790001Medicare NSC
MI4212833Medicaid