Healthcare Provider Details

I. General information

NPI: 1679576870
Provider Name (Legal Business Name): CARLOS A LEON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 PARK AVENUE SUITE 101-B
ORANGE PARK FL
32073-5072
US

IV. Provider business mailing address

2300 PARK AVENUE SUITE 101-B
ORANGE PARK FL
32073-5072
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-0088
  • Fax: 904-264-0099
Mailing address:
  • Phone: 904-264-0088
  • Fax: 904-264-0099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME56274
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number023844
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: