Basic Information
| Provider Information | |||||||||
| NPI: | 1629239165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONG | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2083 COMPTON AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928817288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514688252 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3660 PARK SIERRA DR | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925053071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512788870 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2008 | ||||||||
| LastUpdateDate: | 12/19/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A106797 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 195917301 | 05 | TX | MEDICAID | 8AN623 | 01 | TX | BCBS | OTHER | A106797 | 01 | CA | CALIFORNIA MEDICAL LICENSE | OTHER |