Healthcare Provider Details

I. General information

NPI: 1518040773
Provider Name (Legal Business Name): LESLIE M FORMAN I M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DUKE UNIVERSITY MEDICAL CTR DUMC 3516
DURHAM NC
27710-0001
US

IV. Provider business mailing address

DUKE UNIVERSITY MEDICAL CTR DUMC 3516
DURHAM NC
27710-0001
US

V. Phone/Fax

Practice location:
  • Phone: 919-668-0205
  • Fax: 919-681-8627
Mailing address:
  • Phone: 919-668-0205
  • Fax: 919-681-8627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number37827
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: