Healthcare Provider Details

I. General information

NPI: 1518961069
Provider Name (Legal Business Name): RUSSELL EVAN LEONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 CALIFORNIA ST RM 108
SAN FRANCISCO CA
94118-1504
US

IV. Provider business mailing address

3838 CALIFORNIA ST ROOM 208
SAN FRANCISCO CA
94118-1522
US

V. Phone/Fax

Practice location:
  • Phone: 415-221-0320
  • Fax: 415-221-0329
Mailing address:
  • Phone: 415-221-0320
  • Fax: 415-221-0329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberG40648
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: