Provider Demographics
NPI:1720585904
Name:LIN, LEO (MD/PHD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:LIN
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MEDICAL DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-1100
Mailing Address - Country:US
Mailing Address - Phone:801-581-4390
Mailing Address - Fax:
Practice Address - Street 1:15 MEDICAL DR STE 1100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-1100
Practice Address - Country:US
Practice Address - Phone:801-581-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11405433-1205207ZP0102X, 207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology