Provider Demographics
NPI:1578531075
Name:MUGFORD, LESLEY B (MD)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:B
Last Name:MUGFORD
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 1:150 LOWER WESTFIELD RD
Mailing Address - Street 2:STE1
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-2767
Mailing Address - Country:US
Mailing Address - Phone:413-536-2393
Mailing Address - Fax:413-563-1087
Practice Address - Street 1:150 LOWER WESTFIELD RD
Practice Address - Street 2:STE1
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2767
Practice Address - Country:US
Practice Address - Phone:413-536-2393
Practice Address - Fax:413-563-1087
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205094174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3208613Medicaid
MAA31048Medicare PIN
MA3208613Medicaid