Provider Demographics
NPI:1881720639
Name:VACA, ANGEL JOSE DE LEON (MD)
Entity type:Individual
Prefix:DR
First Name:ANGEL JOSE
Middle Name:DE LEON
Last Name:VACA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13355 CHERRYLAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-6918
Mailing Address - Country:US
Mailing Address - Phone:951-653-6790
Mailing Address - Fax:
Practice Address - Street 1:6969 BROCKTON AVE
Practice Address - Street 2:# B
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3813
Practice Address - Country:US
Practice Address - Phone:951-686-3575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90351207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A903510Medicaid
CA00A903510Medicaid