Provider Demographics
NPI:1154321347
Name:LE, CHINH VAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHINH
Middle Name:VAN
Last Name:LE
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 1:2100 DORCHESTER AVENUE
Mailing Address - Street 2:FAMILY MEDICINE
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124
Mailing Address - Country:US
Mailing Address - Phone:617-506-4970
Mailing Address - Fax:617-825-2352
Practice Address - Street 1:2100 DORCHESTER AVENUE
Practice Address - Street 2:FAMILY MEDICINE
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124
Practice Address - Country:US
Practice Address - Phone:617-506-4970
Practice Address - Fax:617-825-2352
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA48346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2087006Medicaid
MAE30217Medicare UPIN
MAE05796Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO.