1679575708 NPI number — LEAH ROSE GARGUENA-BACUTA M.D.

Table of content: LEAH ROSE GARGUENA-BACUTA M.D. (NPI 1679575708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679575708 NPI number — LEAH ROSE GARGUENA-BACUTA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARGUENA-BACUTA
Provider First Name:
LEAH
Provider Middle Name:
ROSE
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:
GARGUENA
Provider Other First Name:
LEAH
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679575708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8702 MONUMENT OAK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOERNE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78015-6509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-698-2436
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7430 BARLITE BLVD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78224-1365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-298-2529
Provider Business Practice Location Address Fax Number:
210-977-8480
Provider Enumeration Date:
06/01/2005

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: 208000000X , with the licence number:  K8163 , 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: 155488301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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