Provider Demographics
NPI:1376514562
Name:MACDONALD, LESLIE (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:MACDONALD
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 1:521 MOUNT AUBURN ST
Mailing Address - Street 2:STE 103
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4191
Mailing Address - Country:US
Mailing Address - Phone:617-926-2414
Mailing Address - Fax:617-926-8152
Practice Address - Street 1:521 MOUNT AUBURN ST
Practice Address - Street 2:STE 103
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4191
Practice Address - Country:US
Practice Address - Phone:617-926-2414
Practice Address - Fax:617-926-8152
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA203471207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3203913Medicaid
MAF12798Medicare UPIN
MA3203913Medicaid