Provider Demographics
NPI:1225251606
Name:DE LEON, JESSE MATA (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:MATA
Last Name:DE LEON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:16660 PARAMOUNT BLVD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-5433
Mailing Address - Country:US
Mailing Address - Phone:562-633-5438
Mailing Address - Fax:562-633-1685
Practice Address - Street 1:16660 PARAMOUNT BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-5433
Practice Address - Country:US
Practice Address - Phone:562-633-5438
Practice Address - Fax:562-633-1685
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA32517207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A325170Medicaid
CAE98627Medicare UPIN
CAWA32517AMedicare ID - Type Unspecified