Provider Demographics
NPI:1982664165
Name:DE LEON, AUGUSTO R JR (MD)
Entity type:Individual
Prefix:
First Name:AUGUSTO
Middle Name:R
Last Name:DE LEON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:20 CYPRESS POINT PKWY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-7528
Practice Address - Country:US
Practice Address - Phone:386-586-7005
Practice Address - Fax:844-867-3940
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066795207R00000X, 173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255265500Medicaid
FL28145OtherBCBS
FL255265500Medicaid
FL28145OtherBCBS
FL28145OtherBCBS