Provider Demographics
NPI:1548291107
Name:DESROULEAUX, LESLY (MD)
Entity type:Individual
Prefix:
First Name:LESLY
Middle Name:
Last Name:DESROULEAUX
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 1:38754 STATE ROAD 80
Mailing Address - Street 2:
Mailing Address - City:BELLE GLADE
Mailing Address - State:FL
Mailing Address - Zip Code:33430-5615
Mailing Address - Country:US
Mailing Address - Phone:561-996-1600
Mailing Address - Fax:561-837-5332
Practice Address - Street 1:38754 STATE ROAD 80
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-5615
Practice Address - Country:US
Practice Address - Phone:561-996-1600
Practice Address - Fax:561-837-5332
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59527207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055145700Medicaid
A63068Medicare UPIN
14882Medicare ID - Type Unspecified