=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760489983
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LLOYD LEIVA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2005
-----------------------------------------------------
Last Update Date | 05/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3904 CORTEZ RD W
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34210-3111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-345-1943
-----------------------------------------------------
Fax | 941-345-1944
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3904 CORTEZ RD W
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34210-3111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-345-1943
-----------------------------------------------------
Fax | 941-345-1944
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | ME80769
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME80769
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------