Healthcare Provider Details

I. General information

NPI: 1124012299
Provider Name (Legal Business Name): LESLIE A MARTIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 CAMBRIDGE ST MOTHER MARY ROSE FL 3
BRIGHTON MA
02135-2907
US

IV. Provider business mailing address

77 WARREN ST. RM 339
BRIGHTON MA
02135
US

V. Phone/Fax

Practice location:
  • Phone: 617-780-3048
  • Fax: 617-789-2959
Mailing address:
  • Phone: 617-562-5359
  • Fax: 617-562-5415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number42799
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: