Healthcare Provider Details

I. General information

NPI: 1184606782
Provider Name (Legal Business Name): LESLIE L GOODWIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9071 S 1300 W #301
WEST JORDAN UT
84088-6672
US

IV. Provider business mailing address

9071 S 1300 W #301
WEST JORDAN UT
84088-6672
US

V. Phone/Fax

Practice location:
  • Phone: 801-565-1162
  • Fax: 801-565-1168
Mailing address:
  • Phone: 801-565-1162
  • Fax: 801-565-1168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number163308-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: