Provider Demographics
NPI:1356352132
Name:LESLIE, EVAN JOEL (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:JOEL
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 1:400 WESTHAMPTON STA
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3330
Mailing Address - Country:US
Mailing Address - Phone:804-287-4200
Mailing Address - Fax:
Practice Address - Street 1:1706 PARK AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-2911
Practice Address - Country:US
Practice Address - Phone:804-543-1786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032665207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006301703Medicaid
B62877Medicare UPIN
180000529Medicare ID - Type Unspecified
C04260Medicare PIN