Provider Demographics
NPI:1417050220
Name:LE, PHONG (OD)
Entity Type:Individual
Prefix:DR
First Name:PHONG
Middle Name:
Last Name:LE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 N HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4903
Mailing Address - Country:US
Mailing Address - Phone:316-683-3078
Mailing Address - Fax:316-683-6636
Practice Address - Street 1:253 N HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4903
Practice Address - Country:US
Practice Address - Phone:316-683-3078
Practice Address - Fax:316-683-6636
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1459152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS656590OtherFIRST GUARD HEALTH PLAN
KS049668OtherBCBS PROVIDER NUMBER
KS4492OtherPRERFERED HEALTH SYSTEMS
KS049668Medicare ID - Type UnspecifiedPROVIDER NUMBER
KSU58647Medicare UPIN