Healthcare Provider Details

I. General information

NPI: 1174592158
Provider Name (Legal Business Name): GREGORY BRUCE LEONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 E HIGHLAND AVE
PATTON CA
92369-7813
US

IV. Provider business mailing address

3102 E HIGHLAND AVE
PATTON CA
92369-7813
US

V. Phone/Fax

Practice location:
  • Phone: 909-425-6509
  • Fax:
Mailing address:
  • Phone: 909-425-6509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD00025101
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberG34482
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberMD00025101
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG34482
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: