Basic Information
| Provider Information | |||||||||
| NPI: | 1689876013 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEYBA | ||||||||
| FirstName: | MARIO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6701 JEFFERSON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057276200 | ||||||||
| FaxNumber: | 5057279590 | ||||||||
| Practice Location | |||||||||
| Address1: | 6701 JEFFERSON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057276200 | ||||||||
| FaxNumber: | 5057279590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 09/14/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 76329 | AZ | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MD2009-0523 | NM | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 68401051 | 05 | NM | MEDICAID |