Provider Demographics
NPI:1417166240
Name:LE, LAN THANH (DO)
Entity Type:Individual
Prefix:
First Name:LAN
Middle Name:THANH
Last Name:LE
Suffix:
Gender:F
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:P O BOX 678610
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8610
Mailing Address - Country:US
Mailing Address - Phone:817-336-7188
Mailing Address - Fax:817-335-9039
Practice Address - Street 1:5632 EDWARDS RANCH RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4149
Practice Address - Country:US
Practice Address - Phone:817-336-7188
Practice Address - Fax:844-231-8865
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2163208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0016SVOtherBCBS
TX205979201Medicaid
TX205979201Medicaid
TX8F22258Medicare PIN