Provider Demographics
NPI:1306188875
Name:MATHEW, LEENA SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:LEENA
Middle Name:SUSAN
Last Name:MATHEW
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 1:2605 QUARRYSTONE LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1476
Mailing Address - Country:US
Mailing Address - Phone:813-679-6278
Mailing Address - Fax:
Practice Address - Street 1:4800 ALBERTA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2709
Practice Address - Country:US
Practice Address - Phone:915-545-8826
Practice Address - Fax:915-545-6975
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXBP100476392080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program