Healthcare Provider Details

I. General information

NPI: 1932112000
Provider Name (Legal Business Name): EDWARD A LEBRIJA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 W 12TH ST STE 112
PERU IN
46970-1654
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY STE 200
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 765-475-2388
  • Fax: 260-479-2928
Mailing address:
  • Phone: 765-475-2388
  • Fax: 260-479-2917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number639
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO60507271
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number304
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001260A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: