Provider Demographics
NPI:1891280442
Name:VANLEEUWEN, BRYANT (MD)
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:VANLEEUWEN
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 1:777 HOSPITAL WAY STE 215
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5175
Mailing Address - Country:US
Mailing Address - Phone:208-239-2770
Mailing Address - Fax:
Practice Address - Street 1:777 HOSPITAL WAY STE 215
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8354208800000X
IDM-17410208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology