Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | R4212 | LA |
NPI | 1083726368 |
---|---|
Provider Name | Jorge Martinez-Leyva |
First Address | Shreveport, LA 71115-2327 |
Second Address | Shreveport, LA 71115-2302 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 17/05/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1196789 | (05) | LA |
D79348 | (02) | LA |