Provider Demographics
NPI:1780898833
Name:DOUGLAS-CHURCHWELL, LESLIE (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:DOUGLAS-CHURCHWELL
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 1:800 HOWARD AVE
Mailing Address - Street 2:YALE PHYSICIANS BUILDING
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:YALE PHYSICIANS BUILDING
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-785-7411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN25944207R00000X
CT55309207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN110103872OtherRR MEDICARE
TN3085941Medicaid
TN3005101OtherBLUE CROSS BLUE SHIELD
TN4509232OtherAETNA
TN4509232OtherAETNA
TN3085941Medicaid