Healthcare Provider Details

I. General information

NPI: 1972277895
Provider Name (Legal Business Name): LEYNGOLD INSTITUTE FOR PLASTIC SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 E GOLDSTONE DR STE 130
MERIDIAN ID
83642-1549
US

IV. Provider business mailing address

3015 E GOLDSTONE DR STE 130
MERIDIAN ID
83642-1549
US

V. Phone/Fax

Practice location:
  • Phone: 208-900-4673
  • Fax:
Mailing address:
  • Phone: 208-900-4673
  • Fax: 208-266-5033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ILYA M LEYNGOLD
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 904-233-1269