Provider Demographics
NPI:1487726238
Name:MCDANIEL, LESLIE D (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:D
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:D
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 74515
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617-5515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 CALIFORNIA DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687
Practice Address - Country:US
Practice Address - Phone:707-448-6841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG600872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G600870Medicaid
E87598Medicare UPIN
CA00G600870Medicaid