Provider Demographics
NPI:1801800933
Name:WYNNE, LESLIE BERNARD III (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:BERNARD
Last Name:WYNNE
Suffix:III
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:PO BOX 60790
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-6790
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-795-8247
Practice Address - Street 1:438 W LAS TUNAS DR
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1216
Practice Address - Country:US
Practice Address - Phone:626-289-5454
Practice Address - Fax:626-457-7172
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2015-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46663207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A466630Medicaid
CA00A466630OtherBLUE SHIELD
D43364Medicare UPIN
CAA46663Medicare ID - Type Unspecified
CAWA46663CMedicare PIN