Provider Demographics
NPI:1689679748
Name:LEO, JIN-SHONE (MD)
Entity Type:Individual
Prefix:
First Name:JIN-SHONE
Middle Name:
Last Name:LEO
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 1:4005 24TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1835
Mailing Address - Country:US
Mailing Address - Phone:806-792-2767
Mailing Address - Fax:806-791-6709
Practice Address - Street 1:4005 24TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1835
Practice Address - Country:US
Practice Address - Phone:806-792-2767
Practice Address - Fax:806-791-6709
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF23232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87471YOtherBLUE CROSS
625862OtherFIRST HEALTH
NMX4609Medicaid
E10631Medicare UPIN
NMX4609Medicaid