Basic Information
| Provider Information | |||||||||
| NPI: | 1497140404 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 E PROSPECT RD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704930112 | ||||||||
| FaxNumber: | 9704931794 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 E PROSPECT RD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704930112 | ||||||||
| FaxNumber: | 9704931794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2015 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | POD.0000853 | CO | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9000179406 | 05 | CO | MEDICAID |