Provider Demographics
NPI:1780662643
Name:LEEVES, WAYNE N (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:N
Last Name:LEEVES
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 1:323 N FANNIN
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-7321
Mailing Address - Country:US
Mailing Address - Phone:903-531-9835
Mailing Address - Fax:
Practice Address - Street 1:4002 TECHNOLOGY CTR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2697
Practice Address - Country:US
Practice Address - Phone:903-247-0484
Practice Address - Fax:903-247-0485
Is Sole Proprietor?:No
Enumeration Date:2006-01-02
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8657208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB24306Medicare UPIN
TXTXB106808Medicare PIN
TX00FB05Medicare ID - Type Unspecified