Provider Demographics
NPI:1144394057
Name:GERONIMO & LEONG, PROFESSIONAL OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:GERONIMO & LEONG, PROFESSIONAL OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-481-2121
Mailing Address - Street 1:15251 E 14TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1905
Mailing Address - Country:US
Mailing Address - Phone:510-481-2121
Mailing Address - Fax:510-481-2129
Practice Address - Street 1:15251 E 14TH ST STE B
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1905
Practice Address - Country:US
Practice Address - Phone:510-481-2121
Practice Address - Fax:510-481-2129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA977152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26906ZOtherMEDICARE NSC (PTAN)