Provider Demographics
NPI:1639125354
Name:LEONG, MICHAEL G (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-862-1191
Mailing Address - Fax:
Practice Address - Street 1:7223 CHURCH ST
Practice Address - Street 2:SUITE C1
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-5869
Practice Address - Country:US
Practice Address - Phone:909-862-1191
Practice Address - Fax:909-796-4158
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA486080Medicaid
CAFO8692Medicare UPIN