Provider Demographics
NPI:1336128602
Name:LEYA, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LEYA
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 1:2160 S FIRST AVE
Mailing Address - Street 2:(FAHEY BLDG., RM. 007)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-3307
Mailing Address - Fax:708-216-4113
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(FAHEY BLDG., RM. 007)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-3307
Practice Address - Fax:708-216-4113
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36066173207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36066173Medicaid
L80990Medicare ID - Type Unspecified
D16010Medicare UPIN
IL36066173Medicaid