Provider Demographics
NPI:1942685425
Name:DE LEON, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:DE LEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 E 106TH ST APT 20
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-4868
Mailing Address - Country:US
Mailing Address - Phone:510-207-7782
Mailing Address - Fax:
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5317
Practice Address - Country:US
Practice Address - Phone:718-963-5807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program