Provider Demographics
NPI:1821167925
Name:BACHOURA, LEON (MD)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:BACHOURA
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 1:1334 W COVINA BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3211
Mailing Address - Country:US
Mailing Address - Phone:909-592-2078
Mailing Address - Fax:909-592-0279
Practice Address - Street 1:1334 W COVINA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3211
Practice Address - Country:US
Practice Address - Phone:909-592-2078
Practice Address - Fax:909-592-0279
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA361860207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A361860Medicaid
CAW14309Medicare ID - Type Unspecified
CA00A361860Medicaid