Provider Demographics
NPI:1922351360
Name:MARA LEYZIN, MD, PC
Entity Type:Organization
Organization Name:MARA LEYZIN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SOLO PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MARA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEYZIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-745-9900
Mailing Address - Street 1:8025 CASTOR AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2733
Mailing Address - Country:US
Mailing Address - Phone:215-745-9900
Mailing Address - Fax:215-745-9902
Practice Address - Street 1:8025 CASTOR AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19152-2733
Practice Address - Country:US
Practice Address - Phone:215-745-9900
Practice Address - Fax:215-745-9902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-032043-E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102634086000Medicaid
PA483999Medicare PIN