Basic Information
| Provider Information | |||||||||
| NPI: | 1366858797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CABRERA | ||||||||
| FirstName: | NICOLO | ||||||||
| MiddleName: | LEYEZA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | CB 8051 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147473535 | ||||||||
| FaxNumber: | 3144545392 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 S TAYLOR AVE | ||||||||
| Address2: | DIV IM INFECTIOUS DISEASE, STE 100 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147471206 | ||||||||
| FaxNumber: | 3144545392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2014 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2021000356 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 2021000356 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 200098915 | 05 | MO | MEDICAID |