Provider Demographics
NPI:1366858797
Name:CABRERA, NICOLO LEYEZA (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLO
Middle Name:LEYEZA
Last Name:CABRERA
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:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-747-1206
Mailing Address - Fax:314-454-5392
Practice Address - Street 1:620 S TAYLOR AVE
Practice Address - Street 2:DIV IM INFECTIOUS DISEASE, STE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1035
Practice Address - Country:US
Practice Address - Phone:314-747-1206
Practice Address - Fax:314-454-5392
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021000356207R00000X, 207RI0200X
IL125065660207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200098915Medicaid