Healthcare Provider Details

I. General information

NPI: 1174506513
Provider Name (Legal Business Name): JACK LEONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N CICERO AVE
CHICAGO IL
60641-5106
US

IV. Provider business mailing address

3000 N CICERO AVE
CHICAGO IL
60641-5106
US

V. Phone/Fax

Practice location:
  • Phone: 773-282-3115
  • Fax: 773-282-0590
Mailing address:
  • Phone: 773-282-3115
  • Fax: 773-282-0590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036070436
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: