1477094639 NPI number — ANDRES MANUEL DE LEON M.D.

Table of content: ANDRES MANUEL DE LEON M.D. (NPI 1477094639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477094639 NPI number — ANDRES MANUEL DE LEON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LEON
Provider First Name:
ANDRES
Provider Middle Name:
MANUEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DE LEON BENEDETTI
Provider Other First Name:
ANDRES
Provider Other Middle Name:
MANUEL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1477094639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
640 MARION ST SE UNIT B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30312-3507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-610-2340
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 JESSE HILL JR DR SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30303-3050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-616-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0008X , with the licence number:  88696 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 88696 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)