Provider Demographics
NPI:1386764785
Name:ROTH, LESLIE AILEEN (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:AILEEN
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 16149
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-0697
Mailing Address - Country:US
Mailing Address - Phone:401-453-9625
Mailing Address - Fax:401-435-7069
Practice Address - Street 1:208 COLLYER ST
Practice Address - Street 2:SUITE 302
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1560
Practice Address - Country:US
Practice Address - Phone:401-553-8312
Practice Address - Fax:401-868-2306
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD429123208600000X
RIMD12703208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007060566Medicare PIN