Provider Demographics
NPI:1679576870
Name:LEON, CARLOS A (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:A
Last Name:LEON
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 1:2300 PARK AVENUE
Mailing Address - Street 2:SUITE 101-B
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5072
Mailing Address - Country:US
Mailing Address - Phone:904-264-0088
Mailing Address - Fax:904-264-0099
Practice Address - Street 1:2300 PARK AVENUE
Practice Address - Street 2:SUITE 101-B
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5072
Practice Address - Country:US
Practice Address - Phone:904-264-0088
Practice Address - Fax:904-264-0099
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56274207RC0000X
GA023844207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100724OtherAVMED
FL2006421OtherAETNA
GA00424135AMedicaid
FL062517500Medicaid
FL08605OtherBCBS
GA814095OtherBCBS
GA00424135CMedicaid
FL08605OtherBCBS
FL060011697Medicare ID - Type UnspecifiedRAILROAD MCARE
GA00424135CMedicaid
FL062517500Medicaid