Provider Demographics
NPI:1487975181
Name:MATTSON, LESLIE DALAZA (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:DALAZA
Last Name:MATTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LESLIE
Other - Middle Name:MAE
Other - Last Name:DALAZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:220 SPRINGFIELD DR STE 210
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2215
Practice Address - Country:US
Practice Address - Phone:630-510-2609
Practice Address - Fax:630-539-6049
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.131651208M00000X
IL036131651207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist