Provider Demographics
NPI:1114924339
Name:LEIVA, NILSA (MD)
Entity Type:Individual
Prefix:
First Name:NILSA
Middle Name:
Last Name:LEIVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NILSA
Other - Middle Name:
Other - Last Name:LEIVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3904 CORTEZ RD W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3111
Mailing Address - Country:US
Mailing Address - Phone:941-345-1943
Mailing Address - Fax:941-345-1944
Practice Address - Street 1:3904 CORTEZ RD W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3111
Practice Address - Country:US
Practice Address - Phone:941-345-1943
Practice Address - Fax:941-345-1944
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82566207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13634OtherFL BCBS
FL280623100Medicaid
FL280623100Medicaid
FL13634XMedicare PIN
FL13634OtherFL BCBS