Provider Demographics
NPI:1396930079
Name:RICKEY, LESLIE MINOR (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:MINOR
Last Name:RICKEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LESLIE
Other - Middle Name:DAWN
Other - Last Name:MINOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:310 CEDAR STREET
Mailing Address - Street 2:FMB 329E
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519
Mailing Address - Country:US
Mailing Address - Phone:203-785-6927
Mailing Address - Fax:203-785-2909
Practice Address - Street 1:310 CEDAR STREET
Practice Address - Street 2:FMB 329E
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519
Practice Address - Country:US
Practice Address - Phone:203-785-6927
Practice Address - Fax:203-785-2909
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0066234208800000X
CT52279208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD014754100Medicaid
MDD0066234OtherMD STATE LICENSE