Basic Information
| Provider Information | |||||||||
| NPI: | 1396930079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKEY | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | MINOR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MINOR | ||||||||
| OtherFirstName: | LESLIE | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 310 CEDAR STREET | ||||||||
| Address2: | FMB 329E | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037856927 | ||||||||
| FaxNumber: | 2037852909 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 CEDAR STREET | ||||||||
| Address2: | FMB 329E | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037856927 | ||||||||
| FaxNumber: | 2037852909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 04/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | D0066234 | MD | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 52279 | CT | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.