Provider Demographics
NPI:1003915836
Name:BELLOSO, LESLIE MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:MICHELLE
Last Name:BELLOSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 DEVONSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-2514
Mailing Address - Country:US
Mailing Address - Phone:410-548-4514
Mailing Address - Fax:
Practice Address - Street 1:3911 DEVONSHIRE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-2514
Practice Address - Country:US
Practice Address - Phone:410-548-4514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD60576207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDVAD000Medicare UPIN