Provider Demographics
NPI:1073566022
Name:LE, ANDRE T (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:T
Last Name:LE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E ELLISON ST STE C
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-4286
Mailing Address - Country:US
Mailing Address - Phone:214-998-0934
Mailing Address - Fax:817-295-9313
Practice Address - Street 1:116 E ELLISON ST STE C
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4286
Practice Address - Country:US
Practice Address - Phone:817-295-9696
Practice Address - Fax:817-295-9313
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6555TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177117201Medicaid
TX8F0158OtherMEDICARE PROVIDER NUMBER
TXTX6555TGOtherOD LICENSE
TXV05327Medicare UPIN