Provider Demographics
NPI:1871527390
Name:MATSUKAWA, LESLIE A (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:A
Last Name:MATSUKAWA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CRESTRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3934
Mailing Address - Country:US
Mailing Address - Phone:970-494-4200
Mailing Address - Fax:970-377-0967
Practice Address - Street 1:525 W OAK ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2612
Practice Address - Country:US
Practice Address - Phone:970-494-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00577232084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47370505Medicaid
CO47370505Medicaid
53253Medicare ID - Type Unspecified
HI04556101Medicaid