Basic Information
Provider Information | |||||||||
NPI: | 1366619231 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NURSE | ||||||||
FirstName: | LESLIE | ||||||||
MiddleName: | ADINAH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5109 DUDLEY LN | ||||||||
Address2: | APT 304 | ||||||||
City: | BETHESDA | ||||||||
State: | MD | ||||||||
PostalCode: | 208145450 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9179921060 | ||||||||
FaxNumber: | 3016185571 | ||||||||
Practice Location | |||||||||
Address1: | 1221 MERCANTILE LANE | ||||||||
Address2: | KAISER PERMANENTE LARGO MEDICAL CENTER | ||||||||
City: | UPPER MARLBORO | ||||||||
State: | MD | ||||||||
PostalCode: | 20774 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9179921060 | ||||||||
FaxNumber: | 3016185571 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2008 | ||||||||
LastUpdateDate: | 01/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 0101245996 | VA | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207Y00000X | 43532 | TN | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207Y00000X | MD038301 | DC | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207Y00000X | D659549 | MD | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   |
No ID Information.