Provider Demographics
NPI:1215012869
Name:LEO, DOUGLAS J (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
Last Name:LEO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16866 SEVILLE AVE
Mailing Address - Street 2:P.O. BOX 2020
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3561
Mailing Address - Country:US
Mailing Address - Phone:909-350-1524
Mailing Address - Fax:909-350-8546
Practice Address - Street 1:16866 SEVILLE AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3561
Practice Address - Country:US
Practice Address - Phone:909-350-1524
Practice Address - Fax:909-350-8546
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA06988152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY48781YMedicaid
CAYYY48781YMedicaid