Provider Demographics
NPI:1114204971
Name:LE, ANDY
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:LE
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 1:5512 GREENWOOD CREEK DR
Mailing Address - Street 2:#424
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109-6977
Mailing Address - Country:US
Mailing Address - Phone:714-383-2684
Mailing Address - Fax:
Practice Address - Street 1:900 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3902
Practice Address - Country:US
Practice Address - Phone:817-347-5887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10041371207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine