Provider Demographics
NPI:1558454603
Name:DE LEON, ERNEST PAUL (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:PAUL
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 1:4225 NW AMERICAN LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-8841
Mailing Address - Country:US
Mailing Address - Phone:386-758-6141
Mailing Address - Fax:
Practice Address - Street 1:4225 NW AMERICAN LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-8841
Practice Address - Country:US
Practice Address - Phone:386-758-6141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0061518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370092500Medicaid
FL14918ZMedicare ID - Type Unspecified
FL370092500Medicaid