Provider Demographics
NPI:1326478777
Name:LESLIE KOROSTOFF MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LESLIE KOROSTOFF MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROSTOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-391-9060
Mailing Address - Street 1:1931 HAMPTON LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-1107
Mailing Address - Country:US
Mailing Address - Phone:818-391-9060
Mailing Address - Fax:
Practice Address - Street 1:191 S BUENA VISTA ST
Practice Address - Street 2:SUITE 340
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4554
Practice Address - Country:US
Practice Address - Phone:818-260-0693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96824207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty