Basic Information
| Provider Information | |||||||||
| NPI: | 1386624435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | VAN | ||||||||
| MiddleName: | AN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4975 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741590975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187474975 | ||||||||
| FaxNumber: | 9187439058 | ||||||||
| Practice Location | |||||||||
| Address1: | 4111 S DARLINGTON AVE | ||||||||
| Address2: | STE 700 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741356348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187474975 | ||||||||
| FaxNumber: | 9187439058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 07/20/2012 | ||||||||
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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 | 2085R0204X | 8783 | HI | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 29063 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200432110A | 05 | OK | MEDICAID |