Healthcare Provider Details

I. General information

NPI: 1093452468
Provider Name (Legal Business Name): GARY WAYNE DE LEON II DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 BROADWAY
RIVIERA BEACH FL
33404-2331
US

IV. Provider business mailing address

2330 S CONGRESS AVE
WEST PALM BEACH FL
33406-7608
US

V. Phone/Fax

Practice location:
  • Phone: 561-432-5849
  • Fax:
Mailing address:
  • Phone: 561-432-5849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberU7411
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS21806
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: