Healthcare Provider Details

I. General information

NPI: 1720367899
Provider Name (Legal Business Name): GABRIEL C LEGER MD CM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 EXECUTIVE DR STE 325
SAN DIEGO CA
92121
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 858-543-8540
  • Fax: 858-657-8814
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberC155902
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: