Provider Demographics
NPI:1174592158
Name:LEONG, GREGORY BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:BRUCE
Last Name:LEONG
Suffix:
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 1:3102 E HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PATTON
Mailing Address - State:CA
Mailing Address - Zip Code:92369-7813
Mailing Address - Country:US
Mailing Address - Phone:909-425-6509
Mailing Address - Fax:
Practice Address - Street 1:3102 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369-7813
Practice Address - Country:US
Practice Address - Phone:909-425-6509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000251012084P0800X, 2084F0202X
CAG344822084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG77741Medicare UPIN
WAAB05510Medicare PIN