Healthcare Provider Details

I. General information

NPI: 1003992579
Provider Name (Legal Business Name): MARA LEYZIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8025 CASTOR AVE
PHILADELPHIA PA
19152-2733
US

IV. Provider business mailing address

8025 CASTOR AVE
PHILADELPHIA PA
19152-2733
US

V. Phone/Fax

Practice location:
  • Phone: 215-745-9900
  • Fax: 215-745-9902
Mailing address:
  • Phone: 215-745-9900
  • Fax: 215-745-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberMD032043E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD032043E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: