1639240732 NPI number — LESLIE N. HEDDLESTON MD

Table of content: LESLIE N. HEDDLESTON MD (NPI 1639240732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639240732 NPI number — LESLIE N. HEDDLESTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEDDLESTON
Provider First Name:
LESLIE
Provider Middle Name:
N.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639240732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 86370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57118-6370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-7510
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1417 S CLIFF AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-8937
Provider Business Practice Location Address Fax Number:
605-322-8938
Provider Enumeration Date:
11/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VM0101X , with the licence number:  3758 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1639240732 . This is a "ARAZ/AMERICA'S PPO" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 283761009502 . This is a "PREFERRED ONE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 774219300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP30795 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 1639240732 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1658 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 3758 . This is a "SD STATE LICENSE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: G54151 . This is a "CALIFORNIA STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 6200053 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025040700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3758 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 4993265 . This is a "BLUE CROSS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 370624200 . This is a "DEPT OF LABOR" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 57105AD06 . This is a "WPS TRICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 658C9HE . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 658C9HE . This is a "CC SYSTEMS/ BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 924114229808 . This is a "PRIMEWEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1639240732 . This is a "MEDICA" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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