Healthcare Provider Details

I. General information

NPI: 1871584482
Provider Name (Legal Business Name): RICHARD VAN LEEUWEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 N 1700 W
LAYTON UT
84041-8803
US

IV. Provider business mailing address

PO BOX 337
LAYTON UT
84041-0337
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-4840
  • Fax: 801-525-8179
Mailing address:
  • Phone: 801-773-4840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number6474961-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: