Provider Demographics
NPI:1982664165
Name:DE LEON, AUGUSTO R JR (MD)
Entity Type:Individual
Prefix:
First Name:AUGUSTO
Middle Name:R
Last Name:DE LEON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9671
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9671
Mailing Address - Country:US
Mailing Address - Phone:386-676-7130
Mailing Address - Fax:386-676-7125
Practice Address - Street 1:309 PALM COAST PKWY NE
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3886
Practice Address - Country:US
Practice Address - Phone:386-445-7073
Practice Address - Fax:386-445-7464
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066795173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01079727OtherRAILROAD
FL28145OtherBCBS
FL255265500Medicaid
FL28145OtherBCBS
FL28145OtherBCBS