Provider Demographics
NPI:1417215179
Name:LE, PHUONG P (MD)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:P
Last Name:LE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:H
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6501 COYLE AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0306
Mailing Address - Country:US
Mailing Address - Phone:916-537-5051
Mailing Address - Fax:
Practice Address - Street 1:6501 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608
Practice Address - Country:US
Practice Address - Phone:916-537-5051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7733208000000X
390200000X
CAA126623208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program