Provider Demographics
NPI:1255113338
Name:DE LEON, GAVIN MICHAEL
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:MICHAEL
Last Name:DE LEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:MICHAEL
Other - Last Name:DE LEON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2440 PETALUMA AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-2424
Mailing Address - Country:US
Mailing Address - Phone:562-981-4403
Mailing Address - Fax:
Practice Address - Street 1:290 N 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4143
Practice Address - Country:US
Practice Address - Phone:408-418-3232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator