Basic Information
| Provider Information | |||||||||
| NPI: | 1396848958 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | LEO | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 331 DRIFTWOOD RD | ||||||||
| Address2: | |||||||||
| City: | CORONA DEL MAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926252635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494543940 | ||||||||
| FaxNumber: | 9497701953 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148344707 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | C31757 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.