Provider Demographics
NPI:1740713536
Name:LE, CUONG KIM (DO)
Entity type:Individual
Prefix:
First Name:CUONG
Middle Name:KIM
Last Name:LE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:863-674-5520
Mailing Address - Fax:863-674-5521
Practice Address - Street 1:930 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LABELLE
Practice Address - State:FL
Practice Address - Zip Code:33935-4448
Practice Address - Country:US
Practice Address - Phone:863-674-5520
Practice Address - Fax:863-674-5521
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16745207Q00000X
FLTBD207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109265100Medicaid