Provider Demographics
NPI:1447243365
Name:LEONG, IDA G (MD)
Entity Type:Individual
Prefix:DR
First Name:IDA
Middle Name:G
Last Name:LEONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 ARROYO SECO
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3147
Mailing Address - Country:US
Mailing Address - Phone:831-462-4595
Mailing Address - Fax:831-457-2328
Practice Address - Street 1:320 RIVER ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2723
Practice Address - Country:US
Practice Address - Phone:831-272-4324
Practice Address - Fax:831-457-2328
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC38441208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC38441OtherMEDICAL LICENSE NO.
CAB20042Medicare UPIN
CA00C384411Medicare ID - Type Unspecified