Provider Demographics
NPI:1578826582
Name:MEHDINASAB, LEYLA (MD)
Entity Type:Individual
Prefix:
First Name:LEYLA
Middle Name:
Last Name:MEHDINASAB
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 1:17201 I H 45 S
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-3311
Mailing Address - Country:US
Mailing Address - Phone:936-270-2099
Mailing Address - Fax:
Practice Address - Street 1:17201 I H 45 S
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385
Practice Address - Country:US
Practice Address - Phone:936-270-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072295A207R00000X
OH35.099546207R00000X
TXQ9866208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX364862803Medicaid
OH0070940Medicaid
WV3810025723Medicaid