Provider Demographics
NPI:1245249424
Name:LEAL, MARY ANN EVA (MD)
Entity type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:EVA
Last Name:LEAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 848
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91012-0848
Mailing Address - Country:US
Mailing Address - Phone:818-952-9437
Mailing Address - Fax:818-952-7966
Practice Address - Street 1:5229 VISTA LEJANA LN
Practice Address - Street 2:
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-1860
Practice Address - Country:US
Practice Address - Phone:818-952-9437
Practice Address - Fax:818-952-7966
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG53053207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G530530OtherMEDI-CAL
CAG530530OtherLICENSE NUMBER
CA00G530530Medicaid
CABL0283755OtherDEA
CA00G530530OtherMEDI-CAL
CAG53053Medicare PIN