Provider Demographics
NPI:1255420485
Name:BERGHASH, LESLIE ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ROBERT
Last Name:BERGHASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 SE HILLMOOR DR
Mailing Address - Street 2:SUITE B105
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7545
Mailing Address - Country:US
Mailing Address - Phone:772-398-9911
Mailing Address - Fax:772-398-4374
Practice Address - Street 1:1801 SE HILLMOOR DR
Practice Address - Street 2:SUITE B105
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7545
Practice Address - Country:US
Practice Address - Phone:772-398-9911
Practice Address - Fax:772-398-4374
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0052176207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255062800Medicaid
FL255062800Medicaid
B72226Medicare UPIN
04890WMedicare ID - Type UnspecifiedOKEE