Provider Demographics
NPI:1508099946
Name:LE, CHUONG THANH (MD)
Entity Type:Individual
Prefix:
First Name:CHUONG
Middle Name:THANH
Last Name:LE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7819 NW 228TH STREET
Mailing Address - Street 2:
Mailing Address - City:RAIFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32026
Mailing Address - Country:US
Mailing Address - Phone:904-368-3454
Mailing Address - Fax:904-368-3475
Practice Address - Street 1:7819 NW 228TH STREET
Practice Address - Street 2:
Practice Address - City:RAIFORD
Practice Address - State:FL
Practice Address - Zip Code:32026
Practice Address - Country:US
Practice Address - Phone:904-368-3454
Practice Address - Fax:904-368-3475
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 50042208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice