Basic Information
| Provider Information | |||||||||
| NPI: | 1871575092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | PHUONG | ||||||||
| MiddleName: | |||||||||
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| Credential: | O.D. | ||||||||
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| OtherLastName: | LE | ||||||||
| OtherFirstName: | PHUONG-Y | ||||||||
| OtherMiddleName: | M. | ||||||||
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| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1025 NW COUCH ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972094131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035447046 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1040 NW 22ND AVE | ||||||||
| Address2: | SUITE 168 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972103057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034137022 | ||||||||
| FaxNumber: | 5034137006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2788 AT | OR | X | Eye and Vision Services Providers | Optometrist | 152WC0802X | 2788 AT | OR | X | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
No ID Information.