Provider Demographics
NPI:1609309368
Name:LEONG, MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LEONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 CASA GRANDE ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-3407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 DE SOTO AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-6701
Practice Address - Country:US
Practice Address - Phone:833-574-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-09
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361607132081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036160713OtherSTATE LICENSE