Provider Demographics
NPI:1285712950
Name:LESLIE, GLENN R (DO)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:LESLIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10 FRANKLIN TPKE
Mailing Address - Street 2:MAHWAH MEDICAL
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430
Mailing Address - Country:US
Mailing Address - Phone:201-529-3380
Mailing Address - Fax:201-529-5913
Practice Address - Street 1:10 FRANKLIN TPKE
Practice Address - Street 2:
Practice Address - City:MAHWAH
Practice Address - State:NJ
Practice Address - Zip Code:07430-1304
Practice Address - Country:US
Practice Address - Phone:201-529-0033
Practice Address - Fax:201-529-5913
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB42681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0K6749OtherHEALTHNET INS ID
NJ223636986OtherTAX ID AS OF 01/01/12
NJBP329OtherOXFORD INS PLAN
NJ222790526OtherTAX ID
NJ223636986OtherTAX ID AS OF 01/01/12
NJ527211Medicare ID - Type UnspecifiedMEDICARE MAHWAH MEDICAL