Provider Demographics
NPI:1164566972
Name:HERTZ, LESLIE M (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:HERTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:M
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3807 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1667
Mailing Address - Country:US
Mailing Address - Phone:262-687-8282
Mailing Address - Fax:262-687-6737
Practice Address - Street 1:3807 SPRING ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1667
Practice Address - Country:US
Practice Address - Phone:262-687-8282
Practice Address - Fax:262-687-6737
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37663208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIG29977Medicare UPIN