Healthcare Provider Details

I. General information

NPI: 1730591777
Provider Name (Legal Business Name): LESLIE J FODEMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2014
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 HILLSPOINT RD
WESTPORT CT
06880-4536
US

IV. Provider business mailing address

12 HILLSPOINT RD
WESTPORT CT
06880-4536
US

V. Phone/Fax

Practice location:
  • Phone: 203-226-3411
  • Fax: 203-226-3411
Mailing address:
  • Phone: 203-226-3411
  • Fax: 203-226-3411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number12646
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12646
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: