Provider Demographics
NPI:1831262252
Name:SIMONSON, LESLIE (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:SIMONSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 43RD ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-5009
Mailing Address - Country:US
Mailing Address - Phone:201-583-1600
Mailing Address - Fax:201-583-1114
Practice Address - Street 1:415 43RD ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-5009
Practice Address - Country:US
Practice Address - Phone:201-583-1600
Practice Address - Fax:201-583-1114
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA069032207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8043604Medicaid
NJG96120Medicare UPIN
NJ8043604Medicaid