Healthcare Provider Details

I. General information

NPI: 1164520474
Provider Name (Legal Business Name): OVIDIO A DE LEON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

912 S WOOD ST NPI-S ROOM 830, MC 913
CHICAGO IL
60612-4300
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 312-996-3584
  • Fax: 312-413-7856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036087657
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: