Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 1072837 | ZZ |
Y | 213EG0000X | General Practice | 1072837 | ZZ |
N | 1223X0400X | Orthodontists | AEIE06429 | ZZ |
NPI | 1033368402 |
---|---|
Provider Name | Jose Mario Leon-Frias |
First Address | Nogales, AZ 85628-2722 |
Second Address | Nogales, SONORA 84000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2008 |
Last Update Date | 10/09/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MXN000070 | SOUTHWEST SERVICE ADMINISTRATORS (01) | AZ |