Healthcare Provider Details

I. General information

NPI: 1467652602
Provider Name (Legal Business Name): ROSITA DE LEON SAN DIEGO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18631 SHERMAN WAY SUITE F
RESEDA CA
91335-4193
US

IV. Provider business mailing address

9148 COLUMBUS AVE
NORTH HILLS CA
91343-2240
US

V. Phone/Fax

Practice location:
  • Phone: 818-996-9961
  • Fax: 636-222-9670
Mailing address:
  • Phone: 818-893-9299
  • Fax: 818-893-9299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA98076
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA98076
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: