Provider Demographics
NPI:1801953237
Name:FREDERIC J LEONG MD INC
Entity type:Organization
Organization Name:FREDERIC J LEONG MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WAITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-497-7214
Mailing Address - Street 1:555 MARIN ST
Mailing Address - Street 2:#220
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-4236
Mailing Address - Country:US
Mailing Address - Phone:805-497-7214
Mailing Address - Fax:805-497-0864
Practice Address - Street 1:555 MARIN ST.
Practice Address - Street 2:SUITE #220
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360
Practice Address - Country:US
Practice Address - Phone:805-497-7214
Practice Address - Fax:805-497-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG714902080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G714901Medicaid