Provider Demographics
NPI:1811966047
Name:BROCCHINI, LESLIE M (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:M
Last Name:BROCCHINI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:COOPER
Other - Last Name:BROCCHINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:19933 GREENLEY RD STE B
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5906
Mailing Address - Country:US
Mailing Address - Phone:209-743-4249
Mailing Address - Fax:209-536-0506
Practice Address - Street 1:19933 GREENLEY RD STE B
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5906
Practice Address - Country:US
Practice Address - Phone:209-743-4249
Practice Address - Fax:209-536-0506
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72362207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A723620Medicaid
00A723620Medicare ID - Type Unspecified
H66494Medicare UPIN