Provider Demographics
NPI:1881667392
Name:NORDBERG, LEIF O (MD)
Entity Type:Individual
Prefix:DR
First Name:LEIF
Middle Name:O
Last Name:NORDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2001 W MAIN ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-4501
Mailing Address - Country:US
Mailing Address - Phone:203-324-4700
Mailing Address - Fax:203-324-5691
Practice Address - Street 1:2001 W MAIN ST
Practice Address - Street 2:SUITE 150
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902
Practice Address - Country:US
Practice Address - Phone:203-324-4700
Practice Address - Fax:203-324-5691
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2018-08-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT042356208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001423566Medicaid
CT001423566Medicaid
CT240000178Medicare ID - Type Unspecified