Provider Demographics
NPI:1992780712
Name:MASSOGLIA, LESLIE GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:GLEN
Last Name:MASSOGLIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LESLIE
Other - Middle Name:GLEN
Other - Last Name:AHLERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4845 SAFARI CT N
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2617
Mailing Address - Country:US
Mailing Address - Phone:507-461-3813
Mailing Address - Fax:651-305-0595
Practice Address - Street 1:4845 SAFARI CT N
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2617
Practice Address - Country:US
Practice Address - Phone:507-461-3813
Practice Address - Fax:952-431-5334
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43602207Q00000X, 207QA0401X, 208VP0000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN117R2BA, 015K3BAOtherBCBS
MN20153OtherSVHP
MN0107062, 39-09161OtherMEDICA
MN117R2BA, 015K3BAOtherMNCARE
MNNA9501028427OtherPREFERRED ONE
MN080172550OtherMEDICARE RAILROAD
MN140964OtherMNCARE-U
MN564110100Medicaid
MNHP33926OtherHEALTH PARTNERS
MN363606405OtherCHAMPUS
MN080012325Medicare ID - Type Unspecified
MNNA9501028427OtherPREFERRED ONE
080011923, 080010196Medicare ID - Type Unspecified