Provider Demographics
NPI:1801880109
Name:GOLDMAN, LESLIE P (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:P
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2139 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2336
Mailing Address - Country:US
Mailing Address - Phone:860-257-4131
Mailing Address - Fax:860-257-4519
Practice Address - Street 1:245 ALVORD PARK RD
Practice Address - Street 2:BLD B
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3493
Practice Address - Country:US
Practice Address - Phone:860-496-0455
Practice Address - Fax:860-496-2793
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT025312207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001253129Medicaid
B38870Medicare UPIN
CT001253129Medicaid