Provider Demographics
NPI:1619960085
Name:LEIRA, ENRIQUE C (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:C
Last Name:LEIRA
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-8755
Mailing Address - Fax:319-356-4505
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-8755
Practice Address - Fax:319-356-4505
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA310812084N0400X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA55024OtherWELLMARK BCBS
IA0142802Medicaid
G35142Medicare UPIN
IA55024OtherWELLMARK BCBS
IA0142802Medicaid