Healthcare Provider Details

I. General information

NPI: 1538451588
Provider Name (Legal Business Name): LEON BATHINI JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 09/20/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 E 3RD ST
SAN BERNARDINO CA
92410
US

IV. Provider business mailing address

1455 EAST 3RD ST.
SAN BERNARDINO CA
92410-0002
US

V. Phone/Fax

Practice location:
  • Phone: 909-382-7100
  • Fax:
Mailing address:
  • Phone: 909-382-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD1823
License Number StateGU
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberBP10056188
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA125822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: