Healthcare Provider Details

I. General information

NPI: 1164981056
Provider Name (Legal Business Name): LESLIE R MILLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E 17TH ST
AMMON ID
83406-6601
US

IV. Provider business mailing address

2705 E 17TH ST
AMMON ID
83406-6669
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax: 208-346-7501
Mailing address:
  • Phone: 208-346-7500
  • Fax: 208-346-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-17907
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberM-17907
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM-17907
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: