Provider Demographics
NPI:1154434462
Name:MAXWELL, LEISA L (DO)
Entity type:Individual
Prefix:
First Name:LEISA
Middle Name:L
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3677
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03061-3677
Mailing Address - Country:US
Mailing Address - Phone:603-577-7900
Mailing Address - Fax:603-577-7972
Practice Address - Street 1:300 DERRY RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NH
Practice Address - Zip Code:03051-3023
Practice Address - Country:US
Practice Address - Phone:603-886-3979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MET0649207Q00000X
TN2003207Q00000X
NH15719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3077200Medicaid
ME432680399Medicaid
TN1515513Medicaid
ME432680399Medicaid
TN103I087173Medicare PIN
MENONEOtherRESIDENT-NO PROV #