Provider Demographics
NPI:1285615864
Name:LEON, MALLORY (DO)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:LEON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25085 PACIFIC CREST ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-3116
Mailing Address - Country:US
Mailing Address - Phone:951-277-5320
Mailing Address - Fax:
Practice Address - Street 1:25085 PACIFIC CREST STREET
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92883
Practice Address - Country:US
Practice Address - Phone:951-277-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND8690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11640Medicaid
ND11640Medicaid
ND20607Medicare ID - Type Unspecified