Provider Demographics
NPI:1942438015
Name:LEISHMAN, BENJAMIN HUGHSTON (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:HUGHSTON
Last Name:LEISHMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9565 S 700 E STE 101
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3482
Mailing Address - Country:US
Mailing Address - Phone:385-202-3937
Mailing Address - Fax:385-212-2484
Practice Address - Street 1:9565 S 700 E STE 101
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-3482
Practice Address - Country:US
Practice Address - Phone:801-572-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT76555999934152WV0400X, 152WX0102X, 152W00000X, 152WL0500X, 152WP0200X, 152WS0006X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1942438015Medicaid
IL046010223Medicaid
IL046010223Medicaid
UTU000079058Medicare PIN