Healthcare Provider Details

I. General information

NPI: 1013994250
Provider Name (Legal Business Name): LESLIE M GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 OLD WINTER GARDEN RD
ORLANDO FL
32835-1381
US

IV. Provider business mailing address

6336 W COLONIAL DR
ORLANDO FL
32818-7812
US

V. Phone/Fax

Practice location:
  • Phone: 407-290-0555
  • Fax: 407-295-0028
Mailing address:
  • Phone: 407-447-4283
  • Fax: 407-447-4274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License NumberME 92185
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: