Healthcare Provider Details

I. General information

NPI: 1114691607
Provider Name (Legal Business Name): NATNICHA LEELAVIWAT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST
LUBBOCK TX
79430-0002
US

IV. Provider business mailing address

223 INDIANA AVE APT 3211
LUBBOCK TX
79415-5369
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-6840
  • Fax: 806-743-3143
Mailing address:
  • Phone: 806-787-6276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10075601
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: