Provider Demographics
NPI:1720196355
Name:LEITER, ANDREW B (MD, PHD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:B
Last Name:LEITER
Suffix:
Gender:M
Credentials:MD, PHD
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 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:508-856-8101
Mailing Address - Fax:508-856-4770
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-3068
Practice Address - Fax:508-856-3981
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44568207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110043177AMedicaid
MA000238101Medicare PIN
MAB95254Medicare UPIN
MAC04871Medicare ID - Type Unspecified