Provider Demographics
NPI:1790885457
Name:SQUIRES, LESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:SQUIRES
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 1:218C SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-1104
Mailing Address - Country:US
Mailing Address - Phone:609-877-0400
Mailing Address - Fax:609-877-1682
Practice Address - Street 1:218C SUNSET RD
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1104
Practice Address - Country:US
Practice Address - Phone:609-877-0400
Practice Address - Fax:609-877-1682
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA051578207R00000X
PAMD027380E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2416808Medicaid
NJ42468OtherUNIVERSITY HEALTH PLAN
NJP3638017OtherOXFORD HEALTH PLAN
NJ00100780100OtherAMERICHOICE
NJ0085744000OtherAMERIHEALTH HMO
NJ1079899OtherAETNA US HEALTHCARE
NJ1263031OtherCIGNA
NJ3K5919OtherHEALTHNET
NJ2278599OtherUNITED HEALTHCARE
NJ60019242OtherHORIZON NJ HEALTH
NJ42468OtherUNIVERSITY HEALTH PLAN
NJ162380Medicare PIN