Healthcare Provider Details

I. General information

NPI: 1366858797
Provider Name (Legal Business Name): NICOLO LEYEZA CABRERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 04/15/2025
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12634 OLIVE BLVD DIV IM INFECTIOUS DISEASE
SAINT LOUIS MO
63141-6337
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-8000
  • Fax: 314-362-9851
Mailing address:
  • Phone: 314-996-8000
  • Fax: 314-362-9851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2021000356
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number2021000356
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: