Provider Demographics
NPI:1164455275
Name:GLASS, LESLIE A (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:A
Last Name:GLASS
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 1:10151 MONTGOMERY BLVD NE BLDG 1
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3670
Mailing Address - Country:US
Mailing Address - Phone:505-855-5503
Mailing Address - Fax:505-855-5533
Practice Address - Street 1:10151 MONTGOMERY BLVD NE BLDG 1
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3670
Practice Address - Country:US
Practice Address - Phone:505-855-5503
Practice Address - Fax:505-855-5533
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86-49174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM013112OtherBCBS OF NM
NM10124Medicaid
NMD35654Medicare UPIN
NM$$$$$$$$$TMedicare PIN