Provider Demographics
NPI:1679668453
Name:GASS, LESLIE ROBIN (DO)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ROBIN
Last Name:GASS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4973
Mailing Address - Country:US
Mailing Address - Phone:207-773-7330
Mailing Address - Fax:207-773-7340
Practice Address - Street 1:535 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4973
Practice Address - Country:US
Practice Address - Phone:207-773-7330
Practice Address - Fax:207-773-7340
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1804204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
1116014OtherAETNA
I46993Medicare UPIN