Provider Demographics
NPI:1558851881
Name:LEIVA, TYLER D
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:D
Last Name:LEIVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N OKLAHOMA AVE APT 2311
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4423
Mailing Address - Country:US
Mailing Address - Phone:225-610-4009
Mailing Address - Fax:
Practice Address - Street 1:700 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5004
Practice Address - Country:US
Practice Address - Phone:405-271-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program