Provider Demographics
NPI:1629081195
Name:KONKIN, LESLIE A (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:KONKIN
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 576158
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-6158
Mailing Address - Country:US
Mailing Address - Phone:209-605-6469
Mailing Address - Fax:
Practice Address - Street 1:1501 OAKDALE RD STE 301
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3382
Practice Address - Country:US
Practice Address - Phone:209-571-5071
Practice Address - Fax:209-577-1157
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24534207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G245341OtherINDIVIDUAL PTAN
CA9703018Medicaid
CA00G245340Medicare ID - Type Unspecified
CA9703018Medicaid