Provider Demographics
NPI:1083726368
Name:MARTINEZ-LEYVA, JORGE (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:MARTINEZ-LEYVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 YOUREE DR
Mailing Address - Street 2:STE 850
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2327
Mailing Address - Country:US
Mailing Address - Phone:318-424-2623
Mailing Address - Fax:318-227-1357
Practice Address - Street 1:8001 YOUREE DR
Practice Address - Street 2:SUITE 850
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2302
Practice Address - Country:US
Practice Address - Phone:318-424-2623
Practice Address - Fax:318-227-1357
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAR4212207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1196789Medicaid
LA5J825Medicare PIN
LA1196789Medicaid