Healthcare Provider Details

I. General information

NPI: 1225251606
Provider Name (Legal Business Name): JESSE MATA DE LEON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16660 PARAMOUNT BLVD SUITE 211
PARAMOUNT CA
90723-5433
US

IV. Provider business mailing address

16660 PARAMOUNT BLVD SUITE 211
PARAMOUNT CA
90723-5433
US

V. Phone/Fax

Practice location:
  • Phone: 562-633-5438
  • Fax: 562-633-1685
Mailing address:
  • Phone: 562-633-5438
  • Fax: 562-633-1685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA32517
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: