Healthcare Provider Details

I. General information

NPI: 1528406733
Provider Name (Legal Business Name): LEILANI ALTAGRACIA SEGURA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E GRANT ST STE 111
MACOMB IL
61455-3315
US

IV. Provider business mailing address

515 E GRANT ST STE 111
MACOMB IL
61455-3315
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-1729
  • Fax: 309-836-1779
Mailing address:
  • Phone: 309-833-1729
  • Fax: 309-836-1779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036171392
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: