Provider Demographics
NPI:1396790960
Name:KUTCHER, LESLIE MARK (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:MARK
Last Name:KUTCHER
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 1:255 BAYVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-7921
Mailing Address - Country:US
Mailing Address - Phone:203-345-7109
Mailing Address - Fax:
Practice Address - Street 1:52 BEACH RD
Practice Address - Street 2:SUITE 207
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6017
Practice Address - Country:US
Practice Address - Phone:203-255-2003
Practice Address - Fax:203-319-7583
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0211512086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0V5161OtherHEALTH NET
CTZS220OtherOXFORD
CT010021151CT01OtherANTHEM BLUE CROSS
CT521151OtherCONNECTICARE
CTZS220OtherOXFORD