Provider Demographics
NPI:1801193875
Name:LDT MEDICAL,PC
Entity Type:Organization
Organization Name:LDT MEDICAL,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:THEODORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-960-2544
Mailing Address - Street 1:1 CROSS ISLAND PLZ
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-1465
Mailing Address - Country:US
Mailing Address - Phone:718-525-9800
Mailing Address - Fax:718-525-9801
Practice Address - Street 1:1 CROSS ISLAND PLZ
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-1465
Practice Address - Country:US
Practice Address - Phone:718-525-9800
Practice Address - Fax:718-525-9801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-27
Last Update Date:2011-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185234261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF20112Medicare UPIN