Provider Demographics
NPI:1972884500
Name:DE LEON, SAMUEL JR
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:DE LEON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25658 N FM 506
Mailing Address - Street 2:
Mailing Address - City:LA FERIA
Mailing Address - State:TX
Mailing Address - Zip Code:78559-4260
Mailing Address - Country:US
Mailing Address - Phone:956-797-3750
Mailing Address - Fax:956-797-3795
Practice Address - Street 1:25658 N FM 506
Practice Address - Street 2:
Practice Address - City:LA FERIA
Practice Address - State:TX
Practice Address - Zip Code:78559-4260
Practice Address - Country:US
Practice Address - Phone:956-797-3750
Practice Address - Fax:956-797-3795
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000372332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6589120001Medicare NSC