Provider Demographics
NPI:1184707325
Name:BRONNER, LESLIE (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:BRONNER
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 1:3125 POPLARWOOD CT.
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-6445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1012 OBERLIN ROAD,
Practice Address - Street 2:SUITE 300
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1135
Practice Address - Country:US
Practice Address - Phone:919-787-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-013722084P0800X
NC89127207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
I22993Medicare ID - Type Unspecified
NC2492766Medicare ID - Type Unspecified
NC89138HFMedicare ID - Type Unspecified