Provider Demographics
NPI:1942228747
Name:LE, CONG VAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CONG
Middle Name:VAN
Last Name:LE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1100 MERCANTILE LANE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774
Mailing Address - Country:US
Mailing Address - Phone:301-249-0022
Mailing Address - Fax:301-249-7640
Practice Address - Street 1:8220 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706
Practice Address - Country:US
Practice Address - Phone:301-459-7990
Practice Address - Fax:301-459-7993
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00312682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E63818Medicare UPIN
DC00B979D98Medicare PIN