Provider Demographics
NPI:1831688647
Name:MOEDANO, LETICIA (MD)
Entity type:Individual
Prefix:DR
First Name:LETICIA
Middle Name:
Last Name:MOEDANO
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 1:2177 S 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6042
Mailing Address - Country:US
Mailing Address - Phone:928-580-9811
Mailing Address - Fax:
Practice Address - Street 1:2025 GALISTEO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2101
Practice Address - Country:US
Practice Address - Phone:602-655-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ63273207Q00000X
NMMD2022-1484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine