Provider Demographics
NPI:1902882962
Name:WASSERMAN, LEONARD (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:
Last Name:WASSERMAN
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:C/O ST MARY'S PROVIDER ENROLLMENT - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8695
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:168 KINSLEY ST STE 20
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3634
Practice Address - Country:US
Practice Address - Phone:603-883-3365
Practice Address - Fax:603-883-5758
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6838207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30005497Medicaid
NHP01630313OtherRAILROAD MEDICARE
NH3076900Medicaid
NH3076900Medicaid
NHT400285890Medicare PIN
NHNH9630Medicare ID - Type Unspecified