Provider Demographics
NPI:1841604956
Name:LE, PHONG (MD)
Entity Type:Individual
Prefix:
First Name:PHONG
Middle Name:
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 1:10090 E SHANNON WOODS CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-4107
Mailing Address - Country:US
Mailing Address - Phone:316-684-2838
Mailing Address - Fax:
Practice Address - Street 1:10090 E SHANNON WOODS CIR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-4107
Practice Address - Country:US
Practice Address - Phone:316-684-2838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMMD.37173.LL207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSK01783024OtherKANSAS DRIVER LICENSE