Provider Demographics
NPI:1902396377
Name:LEIVA, ORLY JR (MD)
Entity type:Individual
Prefix:DR
First Name:ORLY
Middle Name:
Last Name:LEIVA
Suffix:JR
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 1:702 MASSACHUSETTS AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4054
Mailing Address - Country:US
Mailing Address - Phone:937-602-9166
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE STE MC6080
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1641
Practice Address - Country:US
Practice Address - Phone:773-702-9461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2024-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036170231390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program