Provider Demographics
NPI:1679587687
Name:HARRIS, LESLIE J (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:J
Last Name:HARRIS
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-0150
Mailing Address - Country:US
Mailing Address - Phone:801-601-2825
Mailing Address - Fax:801-562-3169
Practice Address - Street 1:3584 W 9000 S STE 405
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5712
Practice Address - Country:US
Practice Address - Phone:801-568-3480
Practice Address - Fax:801-562-3169
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT280706-8905174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000060696Medicare PIN
UTA23859Medicare UPIN