1245579648 NPI number — MARIA LILIAN LEON M.D

Table of content: MARIA LILIAN LEON M.D (NPI 1245579648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245579648 NPI number — MARIA LILIAN LEON M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEON
Provider First Name:
MARIA
Provider Middle Name:
LILIAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
F

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:
1245579648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3230 INTERSTATE 30 STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESQUITE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75150-2662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-682-1791
Provider Business Mailing Address Fax Number:
972-698-7641

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5315 ROSS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75206-7418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-826-2151
Provider Business Practice Location Address Fax Number:
214-826-2196
Provider Enumeration Date:
02/05/2013

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: 208000000X , with the licence number:  Q4175 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010562155 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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