Healthcare Provider Details

I. General information

NPI: 1184042202
Provider Name (Legal Business Name): BENJAMIN LEONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26740 TOWNE CENTRE DR BLDG C
FOOTHILL RANCH CA
92610-2839
US

IV. Provider business mailing address

11 TECHNOLOGY DR
IRVINE CA
92618-2302
US

V. Phone/Fax

Practice location:
  • Phone: 949-588-9293
  • Fax: 949-588-0409
Mailing address:
  • Phone: 949-923-3488
  • Fax: 855-812-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA141044
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: