Provider Demographics
NPI:1124012299
Name:MARTIN, LESLIE A (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 WARREN ST.
Mailing Address - Street 2:RM 339
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135
Mailing Address - Country:US
Mailing Address - Phone:617-562-5359
Mailing Address - Fax:617-562-5415
Practice Address - Street 1:736 CAMBRIDGE ST
Practice Address - Street 2:MOTHER MARY ROSE FL 3
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2907
Practice Address - Country:US
Practice Address - Phone:617-780-3048
Practice Address - Fax:617-789-2959
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA42799207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0195774Medicaid
B73286Medicare UPIN
K08335Medicare ID - Type Unspecified