Healthcare Provider Details

I. General information

NPI: 1689776775
Provider Name (Legal Business Name): LEON PETER Y CHUA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N BROADWAY SUITE 17
BLYTHE CA
92225-1279
US

IV. Provider business mailing address

500 N BROADWAY SUITE 17
BLYTHE CA
92225-1279
US

V. Phone/Fax

Practice location:
  • Phone: 760-922-2152
  • Fax: 760-922-2292
Mailing address:
  • Phone: 760-922-2152
  • Fax: 760-922-2292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC42412
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: