Provider Demographics
NPI:1467708065
Name:LEONIDES MEDRANO, MD,PA
Entity Type:Organization
Organization Name:LEONIDES MEDRANO, MD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONIDES
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDRANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PA
Authorized Official - Phone:409-883-6052
Mailing Address - Street 1:3321 RIDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630-4235
Mailing Address - Country:US
Mailing Address - Phone:409-883-6052
Mailing Address - Fax:409-883-9620
Practice Address - Street 1:3321 RIDGEMONT DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-4235
Practice Address - Country:US
Practice Address - Phone:409-883-6052
Practice Address - Fax:409-883-9620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5407208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120509801Medicaid
TX1255300695OtherTYPE 1 NPI
TX120509801Medicaid