Provider Demographics
NPI:1740247022
Name:BRUCH, LESLIE A (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:BRUCH
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-384-8871
Mailing Address - Fax:319-384-8053
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-384-8871
Practice Address - Fax:319-384-8053
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36532207ZN0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA11086OtherWELLMARK BCBS
IA11646OtherWELLMARK BCBS
IA1536318Medicaid
IA2536318Medicaid
IA11646OtherWELLMARK BCBS
IAP00347211Medicare PIN
IAI17782Medicare PIN
IA11086OtherWELLMARK BCBS