Provider Demographics
NPI:1720015324
Name:FREDERIKSEN, LESLIE GINGER (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:GINGER
Last Name:FREDERIKSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GINGER
Other - Middle Name:
Other - Last Name:BUDD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 560825
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-0825
Mailing Address - Country:US
Mailing Address - Phone:719-595-7580
Mailing Address - Fax:719-545-0176
Practice Address - Street 1:4010 JERRY MURPHY ROAD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1045
Practice Address - Country:US
Practice Address - Phone:719-546-2229
Practice Address - Fax:719-583-9069
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41018207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48506311Medicaid
CO11199754OtherCAQH
COD009OtherCHAMPUS
COD009OtherCHAMPUS
CO48506311Medicaid
CO535668Medicare ID - Type Unspecified
COP00331010Medicare PIN