Provider Demographics
NPI:1003460999
Name:LEIVA, CARLOS ENRIQUE
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ENRIQUE
Last Name:LEIVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 SW 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2426
Mailing Address - Country:US
Mailing Address - Phone:786-366-1153
Mailing Address - Fax:
Practice Address - Street 1:206 SW 76TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2426
Practice Address - Country:US
Practice Address - Phone:786-366-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11003521363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily