Provider Demographics
NPI:1770211666
Name:LEON, EVERARDO
Entity type:Individual
Prefix:
First Name:EVERARDO
Middle Name:
Last Name:LEON
Suffix:
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 1:1173 GRIZZLY PEAK BLVD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94708-1740
Mailing Address - Country:US
Mailing Address - Phone:323-365-1341
Mailing Address - Fax:
Practice Address - Street 1:100 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAN QUENTIN
Practice Address - State:CA
Practice Address - Zip Code:94964
Practice Address - Country:US
Practice Address - Phone:415-250-7289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program