Provider Demographics
NPI:1184685299
Name:LEONG, FAH S (MD)
Entity Type:Individual
Prefix:
First Name:FAH
Middle Name:S
Last Name:LEONG
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 1:2140 E SOUTHLAKE BLVD # L-824
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6516
Mailing Address - Country:US
Mailing Address - Phone:806-236-5517
Mailing Address - Fax:
Practice Address - Street 1:2140 E SOUTHLAKE BLVD # L-824
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6516
Practice Address - Country:US
Practice Address - Phone:068-236-5517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK227462085R0202X
TXL45232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100212100AMedicaid
NM65050347Medicaid
TXMDL4523OtherWORKERS COMPENSATION
TX8F7702OtherBLUE CROSS
TX151157802Medicaid
128699100OtherFIRSTCARE
TX276243YQDAMedicare PIN
OK100212100AMedicaid
TX8F7889Medicare PIN
TXMDL4523OtherWORKERS COMPENSATION