Provider Demographics
NPI:1023122611
Name:COOPER, LESLIE W (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:W
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E SOUTH TEMPLE STE 515
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1380
Mailing Address - Country:US
Mailing Address - Phone:801-415-1828
Mailing Address - Fax:801-384-0463
Practice Address - Street 1:420 E SOUTH TEMPLE STE 515
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1380
Practice Address - Country:US
Practice Address - Phone:801-415-1828
Practice Address - Fax:801-384-0463
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5614879-1205207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT735332OtherDMBA
UTD5485Medicaid
UT735332OtherFAMILY MEDICINE
UT608933900OtherDOL TAX ID 870640775
UT005516031Medicare ID - Type UnspecifiedTAX ID 870564069
UTD5485Medicaid
UT81057OtherPEHP TAX ID 870640775
UT735332OtherDMBA
UT56148791202001OtherBCBS TAX ID 870616107
UT005585722Medicare ID - Type UnspecifiedTAX ID 870640775
NV100504432Medicaid
UT378821200OtherDOL TAX ID 870616107
UT56148791201001OtherBCBS TAX ID 870640775
UTQM0000025083OtherALTIUS TAX ID 870616107
UT56148791203001OtherBCBS TAX ID 830458867
UT219354OtherALTIUS TAX ID 870564069
UT190475000OtherDOL TAX ID 870564069
UT055335250Medicare ID - Type UnspecifiedTAX ID 870616107
ID807029400Medicaid
UT56148791200001OtherBCBS TAX ID 870564069