Provider Demographics
NPI:1164491783
Name:LE, TIM ZUNG TRI (DO)
Entity Type:Individual
Prefix:DR
First Name:TIM
Middle Name:ZUNG TRI
Last Name:LE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 MORRO BAY DR
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1021
Mailing Address - Country:US
Mailing Address - Phone:949-219-0760
Mailing Address - Fax:714-905-0075
Practice Address - Street 1:2776 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2613
Practice Address - Country:US
Practice Address - Phone:562-997-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7547207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX75420Medicaid
CA00AX75420Medicaid
CAW20A7547BMedicare ID - Type Unspecified