Healthcare Provider Details

I. General information

NPI: 1013409184
Provider Name (Legal Business Name): JACKY LEONG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 READE PLACE
POUGHKEEPSIE NY
12601
US

IV. Provider business mailing address

450 CLARKSON AVE
BROOKLYN NY
11203-2012
US

V. Phone/Fax

Practice location:
  • Phone: 845-454-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MB11737900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number312799
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: