Basic Information
| Provider Information | |||||||||
| NPI: | 1285712950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LESLIE | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 FRANKLIN TPKE | ||||||||
| Address2: | MAHWAH MEDICAL | ||||||||
| City: | MAHWAH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015293380 | ||||||||
| FaxNumber: | 2015295913 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 FRANKLIN TPKE | ||||||||
| Address2: | |||||||||
| City: | MAHWAH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074301304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015290033 | ||||||||
| FaxNumber: | 2015295913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MB42681 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0K6749 | 01 | NJ | HEALTHNET INS ID | OTHER | 223636986 | 01 | NJ | TAX ID AS OF 01/01/12 | OTHER | BP329 | 01 | NJ | OXFORD INS PLAN | OTHER | 222790526 | 01 | NJ | TAX ID | OTHER |