Provider Demographics
NPI:1003992579
Name:LEYZIN, MARA (MD)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:LEYZIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8025 CASTOR AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2733
Mailing Address - Country:US
Mailing Address - Phone:215-745-9900
Mailing Address - Fax:215-745-9902
Practice Address - Street 1:8025 CASTOR AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2733
Practice Address - Country:US
Practice Address - Phone:215-745-9900
Practice Address - Fax:215-745-9902
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032043E207QA0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001153363Medicaid
PA483999Medicare PIN
PAB42245Medicare UPIN