MEDICARE: DR. LESLIE SHU-TUNG FANG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	39471	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	706451	OTHER	MA	TUFTS HEALTH PLAN
2	M09530	OTHER	MA	BCBS MA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558351734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LESLIE SHU-TUNG FANG MD

Provider Business Mailing Address
First Line	:	PO BOX 9142
Second Line	:
City	:	CHARLESTOWN
State	:	MA
Zip	:	02129-9142
Country	:	US
Telephone Number	:	617-742-2054
Fax Number	:	617-742-3157

Provider Business Practice Location Address
First Line	:	151 MERRIMAC ST
Second Line	:	3RD FL
City	:	BOSTON
State	:	MA
Zip	:	02114-4714
Country	:	US
Telephone Number	:	617-742-2054
Fax Number	:	617-742-3157

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	04/22/2014

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