Healthcare Provider Details

I. General information

NPI: 1447421862
Provider Name (Legal Business Name): LESLIE R. GASS, D.O., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 OCEAN AVE
PORTLAND ME
04103-4973
US

IV. Provider business mailing address

535 OCEAN AVE
PORTLAND ME
04103-4973
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-7330
  • Fax: 207-773-7340
Mailing address:
  • Phone: 207-773-7330
  • Fax: 207-773-7340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number1804
License Number StateME

VIII. Authorized Official

Name: LESLIE R. GASS
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 207-773-7330