Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 6610915 | UT |
Y | 213EG0000X | General Practice | 6610915 | UT |
NPI | 1003016536 |
---|---|
Provider Name | Dr. Adam Richard Van Leeuwen |
First Address | Salt Lake City, UT 84121-9999 |
Second Address | Salt Lake City, UT 84121-5999 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/07/2007 |
Last Update Date | 23/07/2007 |