Provider Demographics
NPI:1760814875
Name:LEON, COLLEEN JANE (IDC)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:JANE
Last Name:LEON
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SURFACE WARFARE MEDICAL INSTITUTE
Mailing Address - Street 2:34101 FARENHOLT AVENUE, BUILDING 14
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5291
Mailing Address - Country:US
Mailing Address - Phone:619-532-6195
Mailing Address - Fax:
Practice Address - Street 1:SURFACE WARFARE MEDICAL INSTITUTE
Practice Address - Street 2:34101 FARENHOLT AVENUE, BUILDING 14
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5291
Practice Address - Country:US
Practice Address - Phone:619-532-6195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman