Healthcare Provider Details

I. General information

NPI: 1699733766
Provider Name (Legal Business Name): SEAN LESON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12512 GARDEN GROVE BLVD
GARDEN GROVE CA
92843-1907
US

IV. Provider business mailing address

12512 GARDEN GROVE BLVD
GARDEN GROVE CA
92843-1907
US

V. Phone/Fax

Practice location:
  • Phone: 714-590-1611
  • Fax: 714-590-1641
Mailing address:
  • Phone: 714-590-1611
  • Fax: 714-590-1641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number20A6461
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number20A6461
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: