Provider Demographics
NPI:1073593000
Name:LE, MIMI NGOC BAO (OD)
Entity Type:Individual
Prefix:DR
First Name:MIMI NGOC BAO
Middle Name:
Last Name:LE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MIMI
Other - Middle Name:NGOCBAO
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:830 CARRIAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703
Mailing Address - Country:US
Mailing Address - Phone:903-316-2092
Mailing Address - Fax:903-508-2500
Practice Address - Street 1:4901 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1325
Practice Address - Country:US
Practice Address - Phone:903-508-2498
Practice Address - Fax:903-508-2500
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6783T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181592001Medicaid
TX181592001Medicaid