Provider Demographics
NPI:1093785198
Name:LIS, LEON EDWARD (MD)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:EDWARD
Last Name:LIS
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:PO BOX 1047
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:612 W DUARTE RD
Practice Address - Street 2:STE 101
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-9220
Practice Address - Country:US
Practice Address - Phone:626-445-4850
Practice Address - Fax:626-445-0482
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG578032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300098057OtherRAILROAD MEDICARE
WG57803FMedicare ID - Type Unspecified
WG57803TMedicare ID - Type Unspecified
WG57803EMedicare ID - Type Unspecified
300098057OtherRAILROAD MEDICARE
WG57803GMedicare ID - Type Unspecified