Provider Demographics
NPI:1437359882
Name:PASSOV, LEO (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:PASSOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7259 S BINGHAM JUNCTION BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4860
Mailing Address - Country:US
Mailing Address - Phone:801-930-3110
Mailing Address - Fax:800-437-5541
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-2218
Practice Address - Fax:612-873-1614
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57535-202084P0800X
MN509422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
WI35353800Medicaid
WI35353800Medicaid
IAENROLLEDMedicaid