Provider Demographics
NPI:1033209416
Name:LE, MARK JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:LE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:12102 LINDEN WALK LN
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-3965
Mailing Address - Country:US
Mailing Address - Phone:832-661-2919
Mailing Address - Fax:
Practice Address - Street 1:5320 GRIGGS RD STE B
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77021-3715
Practice Address - Country:US
Practice Address - Phone:832-661-2919
Practice Address - Fax:713-242-9096
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6648T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTPI307581401Medicaid