Provider Demographics
NPI:1154305738
Name:FORGOSH, LESLIE B (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:B
Last Name:FORGOSH
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 1:45 10TH ST W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1062
Mailing Address - Country:US
Mailing Address - Phone:651-232-3000
Mailing Address - Fax:
Practice Address - Street 1:45 10TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1062
Practice Address - Country:US
Practice Address - Phone:651-232-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40393207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN768317100Medicaid
WI3409300Medicaid
060002158Medicare ID - Type Unspecified
WI3409300Medicaid