1245374537 NPI number — JEFFREY K LEITKO MD

Table of content: JEFFREY K LEITKO MD (NPI 1245374537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245374537 NPI number — JEFFREY K LEITKO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEITKO
Provider First Name:
JEFFREY
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245374537
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1845 PRECINCT LINE RD STE 209
Provider Second Line Business Mailing Address:
SECOND FLOOR
Provider Business Mailing Address City Name:
HURST
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76054-3109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-336-4638
Provider Business Mailing Address Fax Number:
817-336-7637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1845 PRECINCT LINE RD STE 209
Provider Second Line Business Practice Location Address:
SECOND FLOOR
Provider Business Practice Location Address City Name:
HURST
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76054-3109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-336-4638
Provider Business Practice Location Address Fax Number:
817-336-7637
Provider Enumeration Date:
02/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  052198 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: M5813 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00463013 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: M5813 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 052198 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 188618601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 26572 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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