Healthcare Provider Details

I. General information

NPI: 1881720639
Provider Name (Legal Business Name): ANGEL JOSE DE LEON VACA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 11/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6969 BROCKTON AVE # B
RIVERSIDE CA
92506-3813
US

IV. Provider business mailing address

13355 CHERRYLAUREL AVE
MORENO VALLEY CA
92553-6918
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-3575
  • Fax:
Mailing address:
  • Phone: 951-653-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA90351
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: