1366423360 NPI number — DR. LESLIE S MASSAD JR. MD

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	MASSAD
Provider First Name	:	LESLIE
Provider Middle Name	:	S
Provider Name Prefix Text	:	DR.
Provider Name Suffix Text	:	JR.
Provider Credential Text	:	MD
Provider Gender Code	:	M

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Provider Other Last Name	:
Provider Other First Name	:
Provider Other Middle Name	:
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Provider Other Name Suffix Text	:
Provider Other Credential Text	:
Provider Other Last Name Type Code	:

NPI Number	:	1366423360
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/17/2009
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
NPI Reactivation Date	:

Provider First Line Business Mailing Address	:	660 S EUCLID AVE
Provider Second Line Business Mailing Address	:	C B 8064
Provider Business Mailing Address City Name	:	SAINT LOUIS
Provider Business Mailing Address State Name	:	MO
Provider Business Mailing Address Postal Code	:	631101010
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	3143623181
Provider Business Mailing Address Fax Number	:	3143628644

Provider First Line Business Practice Location Address	:	4921 PARKVIEW PL
Provider Second Line Business Practice Location Address	:	STE C13
Provider Business Practice Location Address City Name	:	SAINT LOUIS
Provider Business Practice Location Address State Name	:	MO
Provider Business Practice Location Address Postal Code	:	631101032
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	3143623181
Provider Business Practice Location Address Fax Number	:	3143628644
Provider Enumeration Date	:	11/08/2005

Authorized Official Last Name	:
Authorized Official First Name	:
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• Taxonomy code: 207VX0201X , with the licence number:  2007025204 , registered in the state of MO .

• Identifier: E86035 . This identifiers is of the category "".
• Identifier: $$$$$$$$$ , issued by the state of ( IL ) . This identifiers is of the category "".
• Identifier: 327220217 . This identifiers is of the category "".
• Identifier: 202889713 , issued by the state of ( MO ) . This identifiers is of the category "".