Provider Demographics
NPI:1114149234
Name:ERNEST DE LEON, MD, PA
Entity Type:Organization
Organization Name:ERNEST DE LEON, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:DE LEON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-758-6141
Mailing Address - Street 1:4225 NW AMERICAN LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4881
Mailing Address - Country:US
Mailing Address - Phone:386-758-6141
Mailing Address - Fax:
Practice Address - Street 1:4225 NW AMERICAN LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4881
Practice Address - Country:US
Practice Address - Phone:386-758-6141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0061518261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF01536Medicare UPIN
FLK1399Medicare ID - Type Unspecified