Provider Demographics
NPI:1932112000
Name:LEBRIJA, EDWARD A (DPM)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:LEBRIJA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:765-475-2388
Mailing Address - Fax:260-479-2917
Practice Address - Street 1:285 W 12TH ST STE 112
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1654
Practice Address - Country:US
Practice Address - Phone:765-475-2388
Practice Address - Fax:260-479-2928
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN639213E00000X
WAPO60507271213ES0103X
OK304213ES0103X
IN07001260A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200445530AMedicaid
IN300005361Medicaid
OK299340YKW9Medicare PIN