Provider Demographics
NPI:1194760678
Name:CENTENERA, LEANDRO XAVIER (MD)
Entity type:Individual
Prefix:
First Name:LEANDRO
Middle Name:XAVIER
Last Name:CENTENERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11516 PINE TOP LN NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6585
Mailing Address - Country:US
Mailing Address - Phone:505-389-5053
Mailing Address - Fax:
Practice Address - Street 1:11516 PINE TOP LN NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-6585
Practice Address - Country:US
Practice Address - Phone:505-389-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0079208D00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0153884Medicaid
NMNM100121Medicare PIN
NMI14683Medicare UPIN
MT0153884Medicaid