Healthcare Provider Details

I. General information

NPI: 1063860617
Provider Name (Legal Business Name): VIRGINIA LEON DEBERMUDEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VIVI LEON M.D.

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 WALKAWAY CT
CLARKSVILLE TN
37043-6741
US

IV. Provider business mailing address

403 WALKAWAY CT
CLARKSVILLE TN
37043-6741
US

V. Phone/Fax

Practice location:
  • Phone: 931-450-8484
  • Fax:
Mailing address:
  • Phone: 931-450-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number178.361
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: