Provider Demographics
NPI:1013994250
Name:GREEN, LESLIE M (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:6336 W COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-7812
Mailing Address - Country:US
Mailing Address - Phone:407-447-4283
Mailing Address - Fax:407-447-4274
Practice Address - Street 1:6320 OLD WINTER GARDEN RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-1381
Practice Address - Country:US
Practice Address - Phone:407-290-0555
Practice Address - Fax:407-295-0028
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 92185170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI28138Medicare UPIN
FL01373YMedicare ID - Type Unspecified