Basic Information
| Provider Information | |||||||||
| NPI: | 1790766244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEIVA | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034184500 | ||||||||
| FaxNumber: | 5034941678 | ||||||||
| Practice Location | |||||||||
| Address1: | 9555 SW BARNES RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032923577 | ||||||||
| FaxNumber: | 5036913615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD 25402 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 022879 | 05 | OR | MEDICAID |