Provider Demographics
NPI:1760523849
Name:GREEN, LESLIE M (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 N HAMILTON RD
Mailing Address - Street 2:STE. 255
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-8703
Mailing Address - Country:US
Mailing Address - Phone:614-337-9100
Mailing Address - Fax:614-337-0027
Practice Address - Street 1:765 N HAMILTON RD
Practice Address - Street 2:STE. 255
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-8703
Practice Address - Country:US
Practice Address - Phone:614-337-9100
Practice Address - Fax:614-337-0027
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.063613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0883754Medicaid
OHGR0773662Medicare ID - Type UnspecifiedMEDICARE PIN-OHIO
OH0883754Medicaid