Healthcare Provider Details

I. General information

NPI: 1639759301
Provider Name (Legal Business Name): LESLIE RAYBOULD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 KRESSON RD
CHERRY HILL NJ
08003-2604
US

IV. Provider business mailing address

710 KRESSON RD
CHERRY HILL NJ
08003-2604
US

V. Phone/Fax

Practice location:
  • Phone: 856-795-3320
  • Fax: 856-795-1213
Mailing address:
  • Phone: 856-795-3320
  • Fax: 856-795-1213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA12331200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: