Provider Demographics
NPI:1265548804
Name:GONDOR, LESLIE GEORGE (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:GEORGE
Last Name:GONDOR
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 1:3541 W BRADDOCK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1915
Mailing Address - Country:US
Mailing Address - Phone:703-379-6020
Mailing Address - Fax:703-820-8799
Practice Address - Street 1:3541 W BRADDOCK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1915
Practice Address - Country:US
Practice Address - Phone:703-379-6020
Practice Address - Fax:703-820-8799
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101223709174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0101223709OtherM.D. LICENSE
VABG6832794OtherDEA LICENSE
DC491202Medicare PIN
VABG6832794OtherDEA LICENSE
VAH64362Medicare UPIN