Provider Demographics
NPI:1780866038
Name:MORETTI, LESLIE C (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:C
Last Name:MORETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 SULLIVAN AVE
Mailing Address - Street 2:#440
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2221
Mailing Address - Country:US
Mailing Address - Phone:650-992-8500
Mailing Address - Fax:650-992-5292
Practice Address - Street 1:1850 SULLIVAN AVE
Practice Address - Street 2:#440
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2221
Practice Address - Country:US
Practice Address - Phone:650-992-8500
Practice Address - Fax:650-992-5292
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15299207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G152990Medicaid
CAA39488Medicare UPIN
CA00G152990Medicaid