Healthcare Provider Details

I. General information

NPI: 1720573009
Provider Name (Legal Business Name): LESLIE ANDERSON MD M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LESLIE WOLOS

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5570 OVERLAND AVE STE 101
SAN DIEGO CA
92123-1215
US

IV. Provider business mailing address

8778 SPECTRUM CENTER BLVD APT B202
SAN DIEGO CA
92123-5023
US

V. Phone/Fax

Practice location:
  • Phone: 858-206-9428
  • Fax:
Mailing address:
  • Phone: 858-285-5967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number156533
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberPENDING
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: