1083886303 NPI number — GRACIELA M LEIJA MD PA

Table of content: (NPI 1083886303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083886303 NPI number — GRACIELA M LEIJA MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACIELA M LEIJA MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1083886303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 E. PRICE RD.
Provider Second Line Business Mailing Address:
STE. E
Provider Business Mailing Address City Name:
BROWNSVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78521-3565
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-504-4800
Provider Business Mailing Address Fax Number:
956-584-4801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
95 E. PRICE RD.
Provider Second Line Business Practice Location Address:
STE. E
Provider Business Practice Location Address City Name:
BROWNSVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78521-3565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-504-4800
Provider Business Practice Location Address Fax Number:
956-504-4801
Provider Enumeration Date:
03/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEIJA
Authorized Official First Name:
GRACIELA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
956-504-4800

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 45D1083322 . This is a "CLIA CERTIFICATE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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