Provider Demographics
NPI:1558328690
Name:LEON, MILTIADIS (MD)
Entity Type:Individual
Prefix:
First Name:MILTIADIS
Middle Name:
Last Name: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 1:3180 EXECUTIVE DRIVE, SUITE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-7610
Mailing Address - Country:US
Mailing Address - Phone:325-944-1240
Mailing Address - Fax:
Practice Address - Street 1:3180 EXECUTIVE DRIVE, SUITE 102
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7610
Practice Address - Country:US
Practice Address - Phone:325-944-1240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0890207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144285706Medicaid
TX8B2168OtherBLUE CROSS/BLUE SHIELD TX
TX144285706Medicaid
TX8F3759Medicare PIN