Basic Information
| Provider Information | |||||||||
| NPI: | 1518011287 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | CAROL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 RIVERPLACE BLVD | ||||||||
| Address2: | SUITE 620 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322079046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043966620 | ||||||||
| FaxNumber: | 9043966528 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 RIVERPLACE BLVD | ||||||||
| Address2: | SUITE 620 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322079046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043966620 | ||||||||
| FaxNumber: | 9043966528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME105966 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | DR.0066950 | CO | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | DR.0066950 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00855547 | 01 | FL | RR MEDICARE | OTHER | 0026292-00 | 05 | FL | MEDICAID | 579975643A | 05 | GA | MEDICAID |