Basic Information
| Provider Information | |||||||||
| NPI: | 1851363485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADRAK | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 ROUTE 168 | ||||||||
| Address2: | |||||||||
| City: | BLACKWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080123233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568576920 | ||||||||
| FaxNumber: | 8564293826 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 ROUTE 168 | ||||||||
| Address2: | |||||||||
| City: | BLACKWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080123233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568576920 | ||||||||
| FaxNumber: | 8564293826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
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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 | 2084P0800X | MB06834200 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 8526109 | 05 | NJ | MEDICAID |