Provider Demographics
NPI:1407116106
Name:LE, DAT TAT (MD EFFECTIVE 6/1/12)
Entity Type:Individual
Prefix:
First Name:DAT
Middle Name:TAT
Last Name:LE
Suffix:
Gender:M
Credentials:MD EFFECTIVE 6/1/12
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BURLINGTON AVE
Mailing Address - Street 2:APT 2-302
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-3934
Mailing Address - Country:US
Mailing Address - Phone:512-940-4970
Mailing Address - Fax:
Practice Address - Street 1:1 GENERAL ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-2961
Practice Address - Country:US
Practice Address - Phone:978-638-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA262627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program