Provider Demographics
NPI:1073595872
Name:BISSON, LESLIE J (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:J
Last Name:BISSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 MAIN ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6755
Mailing Address - Country:US
Mailing Address - Phone:716-204-3200
Mailing Address - Fax:
Practice Address - Street 1:4949 HARLEM RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-2500
Practice Address - Country:US
Practice Address - Phone:716-312-4684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ76011Medicare ID - Type UnspecifiedMEDICARE #
NYG38807Medicare UPIN