Provider Demographics
NPI:1629170782
Name:LEONG, JACKIE (MD)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:LEONG
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 1:1419 35TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-3727
Mailing Address - Country:US
Mailing Address - Phone:914-747-2438
Mailing Address - Fax:
Practice Address - Street 1:1419 35TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3727
Practice Address - Country:US
Practice Address - Phone:914-747-2438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA059415002085B0100X, 2085N0904X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Not Answered2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0058289Medicaid
F26545Medicare UPIN
NJ0058289Medicaid