Provider Demographics
NPI:1730591777
Name:FODEMAN, LESLIE J (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:J
Last Name:FODEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HILLSPOINT RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4536
Mailing Address - Country:US
Mailing Address - Phone:203-226-3411
Mailing Address - Fax:203-226-3411
Practice Address - Street 1:12 HILLSPOINT RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4536
Practice Address - Country:US
Practice Address - Phone:203-226-3411
Practice Address - Fax:203-226-3411
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-26
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12646207R00000X, 173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No173000000XOther Service ProvidersLegal Medicine