Provider Demographics
NPI:1861628844
Name:LAN LE, DO, P.A.
Entity Type:Organization
Organization Name:LAN LE, DO, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-336-7188
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-04
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2163208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205978401Medicaid
TX0016SVOtherBCBS
TXDP5736Medicare PIN
TX0A4841Medicare PIN