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General NPI Number Information
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NPI Number | 1881895233
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Entity Type | Individual
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Provider Name | RODOLFO LEONGSON SAN JUAN JR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 09/14/2023
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Provider Practice Location Address
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Address Line | 11161 RANDOLPH ST
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City | CROWN POINT
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State | IN
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Zip | 46307-8564
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Country | US
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Telephone | 219-662-9424
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Fax | 219-662-7465
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Provider Business Mailing Address
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Address Line | PO BOX 781076
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City | DETROIT
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State | MI
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Zip | 48278-1076
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Country | US
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Telephone | 317-528-4800
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Fax | 317-865-1479
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0116017383
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 01064429A
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License Number State | IN
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