Provider Demographics
NPI:1174684708
Name:LEONG, ELIZABETH T (RD)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:T
Last Name:LEONG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:AN-LI
Other - Last Name:TSAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:62 RICHARDSON RD
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6170
Mailing Address - Country:US
Mailing Address - Phone:415-506-0138
Mailing Address - Fax:415-506-0187
Practice Address - Street 1:1904 FRANKLIN ST STE 801
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2915
Practice Address - Country:US
Practice Address - Phone:510-922-8208
Practice Address - Fax:510-550-7966
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA354976133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ25190ZMedicare PIN