Provider Demographics
NPI:1689776775
Name:CHUA, LEON PETER Y (MD)
Entity Type:Individual
Prefix:
First Name:LEON PETER
Middle Name:Y
Last Name:CHUA
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 1:500 N BROADWAY
Mailing Address - Street 2:SUITE 17
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92225-1279
Mailing Address - Country:US
Mailing Address - Phone:760-922-2152
Mailing Address - Fax:760-922-2292
Practice Address - Street 1:500 N BROADWAY
Practice Address - Street 2:SUITE 17
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-1279
Practice Address - Country:US
Practice Address - Phone:760-922-2152
Practice Address - Fax:760-922-2292
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
CAC42412207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC42412OtherLICENSE NUMBER
CAD05909Medicare UPIN