Provider Demographics
NPI:1841302411
Name:LEIS, ANGEL ARTURO (MD)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:ARTURO
Last Name:LEIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 E WOODROW WILSON AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5112
Mailing Address - Country:US
Mailing Address - Phone:601-981-1234
Mailing Address - Fax:601-981-3989
Practice Address - Street 1:1350 E WOODROW WILSON AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5112
Practice Address - Country:US
Practice Address - Phone:601-981-1234
Practice Address - Fax:601-981-3989
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS136672084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015353Medicaid
A03388Medicare UPIN