Provider Demographics
NPI:1396937363
Name:NAVARAVONG, LEENHAPONG (MD)
Entity type:Individual
Prefix:MR
First Name:LEENHAPONG
Middle Name:
Last Name:NAVARAVONG
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 1:395 W COUGAR BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3311
Mailing Address - Country:US
Mailing Address - Phone:435-357-4600
Mailing Address - Fax:
Practice Address - Street 1:395 W COUGAR BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3311
Practice Address - Country:US
Practice Address - Phone:435-357-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8237582-1205207R00000X, 207RC0000X, 207RC0001X
IAMD-42118207RC0000X
IA42118207RC0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1396937363Medicaid
IAP01437247OtherRR MEDICARE
IA1396937363Medicaid