Provider Demographics
NPI:1558396770
Name:SACKSCHEWSKY, LESLIE D (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:D
Last Name:SACKSCHEWSKY
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 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-524-1211
Mailing Address - Fax:
Practice Address - Street 1:999 S FAIRMONT AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240
Practice Address - Country:US
Practice Address - Phone:209-334-3333
Practice Address - Fax:209-369-2641
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79025207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0022330Medicaid
CACG470YMedicare PIN
CAGR0022330Medicaid