Provider Demographics
NPI:1356432009
Name:LEROY, ELLIS WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:WILLIAM
Last Name:LEROY
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 1:1055 N 500 W
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-429-8000
Mailing Address - Fax:801-429-8150
Practice Address - Street 1:1120 E 100 N
Practice Address - Street 2:# 1
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651
Practice Address - Country:US
Practice Address - Phone:801-465-4813
Practice Address - Fax:801-465-7207
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2025-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT159570-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT22811OtherPEHP
UT36374OtherDMBA
UT870281028EWJOtherEMIA
UT110090648OtherPALMETTO
UT87028108000Medicaid
UT04-00323OtherUTAH HEALTHCARE
UT10700660401OtherIHC
UTQMXAF0342OtherALTIUS
UT005502567Medicare ID - Type UnspecifiedMEDICARE
UT87028108000Medicaid
UT005502567Medicare PIN