Provider Demographics
NPI:1083720072
Name:MIYA, LESLIE Y (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:Y
Last Name:MIYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 HOMESTEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-4427
Mailing Address - Country:US
Mailing Address - Phone:415-381-7967
Mailing Address - Fax:
Practice Address - Street 1:57 HOMESTEAD BLVD
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-4427
Practice Address - Country:US
Practice Address - Phone:415-381-7967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033987207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine