Provider Demographics
NPI:1346602000
Name:LEIVA, STEPHANIE M (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:LEIVA
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 1:930 LAKE BALDWIN LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6651
Mailing Address - Country:US
Mailing Address - Phone:407-898-1500
Mailing Address - Fax:
Practice Address - Street 1:930 LAKE BALDWIN LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6651
Practice Address - Country:US
Practice Address - Phone:407-898-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME160822207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117419300Medicaid