MEDICARE: LESLIE Y MIYA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD00033987	WA

General Provider Information

NPI Number	:	1083720072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE Y MIYA MD

Provider Business Mailing Address
First Line	:	57 HOMESTEAD BLVD
Second Line	:
City	:	MILL VALLEY
State	:	CA
Zip	:	94941-4427
Country	:	US
Telephone Number	:	415-381-7967
Fax Number	:

Provider Business Practice Location Address
First Line	:	57 HOMESTEAD BLVD
Second Line	:
City	:	MILL VALLEY
State	:	CA
Zip	:	94941-4427
Country	:	US
Telephone Number	:	415-381-7967
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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