1588660047 NPI number — DR. LEAH RAYE MABRY MD

Table of content: DR. LEAH RAYE MABRY MD (NPI 1588660047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588660047 NPI number — DR. LEAH RAYE MABRY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MABRY
Provider First Name:
LEAH RAYE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1588660047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 N. SANTA ROSA
Provider Second Line Business Mailing Address:
CENTER FOR CHILDREN & FAMILIES, SUITE 4703
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-704-2535
Provider Business Mailing Address Fax Number:
210-704-2545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 N. SANTA ROSA
Provider Second Line Business Practice Location Address:
CENTER FOR CHILDREN & FAMILIES, 4TH FLOOR
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-704-4140
Provider Business Practice Location Address Fax Number:
210-704-4136
Provider Enumeration Date:
06/21/2005

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: 207Q00000X , with the licence number:  G3574 , 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: 5986554 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2224540 . This is a "BLUELINK ACCESS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 130776107 . This is a "CIDC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 436404 . This is a "PRIVATE HEALTHCARE SYST" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 773119 . This is a "FIRST HEALTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 85747F . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 742806531E . This is a "HUMANA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 130776102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7677915002 . This is a "CIGNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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