Provider Demographics
NPI:1356483663
Name:DE LEON, RANDOLFO (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLFO
Middle Name:
Last Name:DE LEON
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 1:2195 DOUBLE L DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:IA
Mailing Address - Zip Code:50644-9658
Mailing Address - Country:US
Mailing Address - Phone:319-334-2310
Mailing Address - Fax:
Practice Address - Street 1:1600 1ST ST E
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:IA
Practice Address - Zip Code:50644-3155
Practice Address - Country:US
Practice Address - Phone:319-334-6071
Practice Address - Fax:319-334-6149
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20387208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D15962Medicare UPIN