Provider Demographics
NPI:1578580403
Name:LEON PETER Y. CHUA, M.D.
Entity Type:Organization
Organization Name:LEON PETER Y. CHUA, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON PETER
Authorized Official - Middle Name:Y
Authorized Official - Last Name:CHUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-922-2152
Mailing Address - Street 1:500 N BROADWAY
Mailing Address - Street 2:STE 17
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92225-1279
Mailing Address - Country:US
Mailing Address - Phone:760-922-2152
Mailing Address - Fax:760-922-2292
Practice Address - Street 1:500 N BROADWAY
Practice Address - Street 2:STE 17
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-1279
Practice Address - Country:US
Practice Address - Phone:760-922-2152
Practice Address - Fax:760-922-2292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42412207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD05909Medicare UPIN