Provider Demographics
NPI:1740495233
Name:DR LEONARDO CHACON, M.D. INC
Entity type:Organization
Organization Name:DR LEONARDO CHACON, M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-835-2147
Mailing Address - Street 1:28832 LEAH CIRCLE
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1721 WILMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744
Practice Address - Country:US
Practice Address - Phone:310-835-2147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA327050305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV50203Medicare UPIN