Provider Demographics
NPI:1649350034
Name:LE, BAOAN GIA (MD)
Entity type:Individual
Prefix:
First Name:BAOAN
Middle Name:GIA
Last Name:LE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANDY
Other - Middle Name:GIA
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2325 E SHEA BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3115
Mailing Address - Country:US
Mailing Address - Phone:918-344-0130
Mailing Address - Fax:
Practice Address - Street 1:4527 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-3702
Practice Address - Country:US
Practice Address - Phone:602-249-4508
Practice Address - Fax:602-249-1614
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 94404207Q00000X
OK23089207Q00000X
AZ36389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKI08654Medicare UPIN