Healthcare Provider Details

I. General information

NPI: 1831451202
Provider Name (Legal Business Name): LESLIE KOFFLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6412 ALDERTON ST
REGO PARK NY
11374-5012
US

IV. Provider business mailing address

64-12 ALDERTON STREET
REGO PARK NY
11374
US

V. Phone/Fax

Practice location:
  • Phone: 646-220-5854
  • Fax:
Mailing address:
  • Phone: 646-220-5854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: