Provider Demographics
NPI:1689876013
Name:LEYBA, MARIO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:LEYBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4318
Mailing Address - Country:US
Mailing Address - Phone:505-727-6200
Mailing Address - Fax:505-727-9590
Practice Address - Street 1:6701 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4318
Practice Address - Country:US
Practice Address - Phone:505-727-6200
Practice Address - Fax:505-727-9590
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ76329208600000X
NMMD2009-0523208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68401051Medicaid
NM68401051Medicaid