Provider Demographics
NPI:1023498532
Name:PORTUGAL, LESLEY ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:LESLEY ANNE
Middle Name:
Last Name:PORTUGAL
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:LESLEY ANNE
Other - Middle Name:CRUZ
Other - Last Name:PORTUGAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3046
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3046
Practice Address - Country:US
Practice Address - Phone:208-882-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14838207R00000X
WAMD60915046207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine