Provider Demographics
NPI:1629239165
Name:LEONG, BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
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 1:2083 COMPTON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-7288
Mailing Address - Country:US
Mailing Address - Phone:951-468-8252
Mailing Address - Fax:
Practice Address - Street 1:3660 PARK SIERRA DR
Practice Address - Street 2:SUITE 105
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3071
Practice Address - Country:US
Practice Address - Phone:951-278-8870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106797208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195917301Medicaid
TX8AN623OtherBCBS
CAA106797OtherCALIFORNIA MEDICAL LICENSE
TX195917301Medicaid