Provider Demographics
NPI:1376568907
Name:LEO, ROBERT G (RT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:LEO
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:RGL
Other - Middle Name:MEDICAL
Other - Last Name:LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1561 W 7000 S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-3556
Mailing Address - Country:US
Mailing Address - Phone:801-568-9895
Mailing Address - Fax:801-352-0400
Practice Address - Street 1:1561 W 7000 S
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-3556
Practice Address - Country:US
Practice Address - Phone:801-568-9895
Practice Address - Fax:801-352-0400
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT116092-5401247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT841375719001Medicaid
UT000090751Medicare PIN
UT841375719001Medicaid