Provider Demographics
NPI:1497863450
Name:FERNOW, LESLEY MONTGOMERY (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLEY
Middle Name:MONTGOMERY
Last Name:FERNOW
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 1:80 COTTON BROOK RD
Mailing Address - Street 2:
Mailing Address - City:DOVER FOXCROFT
Mailing Address - State:ME
Mailing Address - Zip Code:04426-3902
Mailing Address - Country:US
Mailing Address - Phone:207-564-3934
Mailing Address - Fax:
Practice Address - Street 1:1048 SOUTH ST
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-1232
Practice Address - Country:US
Practice Address - Phone:207-564-7131
Practice Address - Fax:207-564-7209
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME9847207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME022208Medicare ID - Type Unspecified
MEC66241Medicare UPIN