Provider Demographics
NPI:1538141247
Name:LEIVA, JORGE I (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:I
Last Name:LEIVA
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 1:21216 NORTHWEST FWY
Mailing Address - Street 2:SUITE#250
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-1439
Mailing Address - Country:US
Mailing Address - Phone:713-426-2400
Mailing Address - Fax:713-426-3204
Practice Address - Street 1:21216 NORTHWEST FWY
Practice Address - Street 2:SUITE#250
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-1439
Practice Address - Country:US
Practice Address - Phone:713-426-2400
Practice Address - Fax:713-426-3204
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK6641208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081177101Medicaid
TX081177101Medicaid
TXH48342Medicare UPIN