1679587265 NPI number — THERESA MARIE LEAK-GONZALEZ MD

Table of content: THERESA MARIE LEAK-GONZALEZ MD (NPI 1679587265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679587265 NPI number — THERESA MARIE LEAK-GONZALEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEAK-GONZALEZ
Provider First Name:
THERESA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
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:
1679587265
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
260 MERRIMAC ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWBURYPORT
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01950-2192
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-499-7200
Provider Business Mailing Address Fax Number:
978-499-7216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
260 MERRIMAC ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWBURYPORT
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01950-2192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-499-7200
Provider Business Practice Location Address Fax Number:
978-499-7216
Provider Enumeration Date:
07/28/2006

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: 207R00000X , with the licence number:  235395 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0844040 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1679587265 . This is a "PHCS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J43036 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0045415 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679587265 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679587265 . This is a "ANTHEM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 1679587265 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 95347501 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: AA120030 . This is a "HPHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: P00983236 . This is a "RR MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 497486 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 110079874A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30207840 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04-55814 . This is a "EVERCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679587265 . This is a "BOSTON MEDICAL CENTER HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679587265 . This is a "FALLON COMMUNITY HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com