Healthcare Provider Details

I. General information

NPI: 1629239165
Provider Name (Legal Business Name): BENJAMIN LEONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 12/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 PARK SIERRA DR SUITE 105
RIVERSIDE CA
92505-3071
US

IV. Provider business mailing address

2083 COMPTON AVE STE 103
CORONA CA
92881-7288
US

V. Phone/Fax

Practice location:
  • Phone: 951-278-8870
  • Fax:
Mailing address:
  • Phone: 951-468-8252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA106797
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: