Provider Demographics
NPI:1801844147
Name:COOPERSMITH, LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:COOPERSMITH
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 1:56 FRANKLIN ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1221
Mailing Address - Country:US
Mailing Address - Phone:203-709-8873
Mailing Address - Fax:203-709-8689
Practice Address - Street 1:133 SCOVILL ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1127
Practice Address - Country:US
Practice Address - Phone:203-709-5680
Practice Address - Fax:203-709-5688
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2013-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT028261207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001282615Medicaid
CT001282615Medicaid
CTE31379Medicare UPIN