=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023422185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN JOSHUA LEUNG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2014
-----------------------------------------------------
Last Update Date | 09/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9239 VISTA WAY
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76126-2451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-737-3331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9239 VISTA WAY
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76126-2451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-737-3331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | V1821
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------