Healthcare Provider Details

I. General information

NPI: 1871739649
Provider Name (Legal Business Name): LESLIE S T FANG, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2008
Last Update Date: 12/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MERRIMAC ST 3RD FLOOR
BOSTON MA
02114-4714
US

IV. Provider business mailing address

151 MERRIMAC ST 3RD FLOOR
BOSTON MA
02114-4714
US

V. Phone/Fax

Practice location:
  • Phone: 617-742-2054
  • Fax: 617-742-3157
Mailing address:
  • Phone: 617-742-2054
  • Fax: 617-742-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number39471
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number39471
License Number StateMA

VIII. Authorized Official

Name: LESLIE SHU TUNG FANG
Title or Position: OWNER
Credential: MD,PHD
Phone: 617-742-2054