Provider Demographics
NPI:1841307261
Name:DOMALIK, LESLIE JEAN (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:JEAN
Last Name:DOMALIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:ACC BUILDING
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-3206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246161207RE0101X
CT039502207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
P2839358OtherOXFORD
010039502CT01OtherANTHEM BCBS
1219546OtherUNITED HEALTHCARE
139502OtherCONNECTICARE
1233211OtherCIGNA HEALTHCARE
2V2568OtherHEALTHNET
1233211OtherCIGNA HEALTHCARE
1219546OtherUNITED HEALTHCARE