Basic Information
| Provider Information | |||||||||
| NPI: | 1275607020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | YUNG | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3156 VISTA WAY | ||||||||
| Address2: | 405 | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920563622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604396581 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3156 VISTA WAY | ||||||||
| Address2: | 405 | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920563622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604396581 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A061766 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00617660 | 05 | CA | MEDICAID |