Provider Demographics
NPI:1558351734
Name:FANG, LESLIE SHU-TUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:SHU-TUNG
Last Name:FANG
Suffix:
Gender:M
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:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-742-2054
Mailing Address - Fax:617-742-3157
Practice Address - Street 1:151 MERRIMAC ST
Practice Address - Street 2:3RD FL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-4714
Practice Address - Country:US
Practice Address - Phone:617-742-2054
Practice Address - Fax:617-742-3157
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39471207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA706451OtherTUFTS HEALTH PLAN
MAM09530OtherBCBS MA
MA110037240/AMedicaid
MAM09530OtherBCBS MA
MAM09530Medicare PIN