Provider Demographics
NPI:1922168129
Name:LEYVA, ILEANA MARIA (MD)
Entity Type:Individual
Prefix:DR
First Name:ILEANA
Middle Name:MARIA
Last Name:LEYVA
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 1:5420 NW 33RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6348
Mailing Address - Country:US
Mailing Address - Phone:954-486-4085
Mailing Address - Fax:
Practice Address - Street 1:5420 NW 33RD AVE STE 100
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-6348
Practice Address - Country:US
Practice Address - Phone:954-486-4085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1306882080H0002X
IL0360897222080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089722Medicaid
IL363149833OtherCDPG TAX IDENTIFICAITON NUMBER
ILCA4748OtherRAILROAD MEDICARE GROUP PTAN
ILL93363OtherPIN
IL36-4450982OtherCOMFORTLINK TAX ID #
IL0222075OtherBLUE CROSS GROUP NUMBER
IL02232008OtherCOMFORTLINK BLUE SHIELD G
IL1033149844OtherGROUP NPI NUMBER
IL3631498336019001OtherHFS GROUP PAYEE ID
IL1922168129OtherNPI NUMBER
ILP00749841OtherRAILROAD MEDICARE PTAN
IL02232008OtherCOMFORTLINK BLUE SHIELD G
IL363149833OtherCDPG TAX IDENTIFICAITON NUMBER
ILP00749841OtherRAILROAD MEDICARE PTAN
IL206147Medicare PIN
ILH69888Medicare UPIN