Provider Demographics
NPI:1518040773
Name:FORMAN, LESLIE M I (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:M
Last Name:FORMAN
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:DUKE UNIVERSITY MEDICAL CTR
Mailing Address - Street 2:DUMC 3516
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27710-0001
Mailing Address - Country:US
Mailing Address - Phone:919-668-0205
Mailing Address - Fax:919-681-8627
Practice Address - Street 1:DUKE UNIVERSITY MEDICAL CTR
Practice Address - Street 2:DUMC 3516
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-0001
Practice Address - Country:US
Practice Address - Phone:919-668-0205
Practice Address - Fax:919-681-8627
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC378272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8933069Medicaid
NC2187415Medicare PIN
B12811Medicare UPIN