Provider Demographics
NPI:1629130539
Name:LESLIE L. OLDENBROOK, D.P.M.
Entity Type:Organization
Organization Name:LESLIE L. OLDENBROOK, D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:OLDENBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:408-379-8450
Mailing Address - Street 1:555 KNOWLES DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1551
Mailing Address - Country:US
Mailing Address - Phone:408-379-8450
Mailing Address - Fax:408-379-2672
Practice Address - Street 1:555 KNOWLES DR
Practice Address - Street 2:SUITE 220
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1551
Practice Address - Country:US
Practice Address - Phone:408-379-8450
Practice Address - Fax:408-379-2672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE20180213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E20180Medicaid
CAZZZ01485ZMedicare PIN
CA4155020001Medicare NSC