1033193990 NPI number — JOHN R LEYENDECKER MD

Table of content: JOHN R LEYENDECKER MD (NPI 1033193990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033193990 NPI number — JOHN R LEYENDECKER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEYENDECKER
Provider First Name:
JOHN
Provider Middle Name:
R
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:
1033193990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 845347
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-5347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-648-7732
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5323 HARRY HINES BLVD
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:
75390-7201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-648-7732
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2005

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: 2085R0202X , with the licence number:  L0377 , 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: 3810000631 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 891361K , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: D5072 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 804390 . This is a "PARTNERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: Q0054J , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1361K . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7801123 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10080754 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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