MEDICARE: ERNEST DE LEON, MD, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	0061518	FL

General Provider Information

NPI Number	:	1114149234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ERNEST DE LEON, MD, PA

Provider Business Mailing Address
First Line	:	4225 NW AMERICAN LN
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-4881
Country	:	US
Telephone Number	:	386-758-6141
Fax Number	:

Provider Business Practice Location Address
First Line	:	4225 NW AMERICAN LN
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-4881
Country	:	US
Telephone Number	:	386-758-6141
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ERNEST PAUL DE LEON
Credential	:	MD
Telephone Number	:	386-758-6141

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	08/22/2020

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