Provider Demographics
NPI:1548375314
Name:LIDONNICI, LESLIE ANNE MARIE (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANNE MARIE
Last Name:LIDONNICI
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 1031
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-1031
Mailing Address - Country:US
Mailing Address - Phone:516-629-2484
Mailing Address - Fax:516-629-2027
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1353
Practice Address - Country:US
Practice Address - Phone:516-629-2484
Practice Address - Fax:516-629-2027
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1385502086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01634775Medicaid
NYG21716Medicare UPIN
NY52L421Medicare ID - Type Unspecified