Provider Demographics
NPI:1205017035
Name:TUAN DAI LE, M.D, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:TUAN DAI LE, M.D, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TUAN
Authorized Official - Middle Name:DAI
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-620-8436
Mailing Address - Street 1:1151 E HOLT AVE
Mailing Address - Street 2:SUITE Q
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5813
Mailing Address - Country:US
Mailing Address - Phone:909-620-8436
Mailing Address - Fax:909-868-5134
Practice Address - Street 1:1151 E HOLT AVE
Practice Address - Street 2:SUITE Q
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5813
Practice Address - Country:US
Practice Address - Phone:909-620-8436
Practice Address - Fax:909-868-5134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60032207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A600321Medicaid
CAG72898Medicare UPIN
CAA60032AMedicare PIN