Basic Information
| Provider Information | |||||||||
| NPI: | 1396953998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | PHUC | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LE | ||||||||
| OtherFirstName: | CAMILLE | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6402 E SUPERSTITION SPRINGS BLVD STE 224 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808356100 | ||||||||
| FaxNumber: | 4804614243 | ||||||||
| Practice Location | |||||||||
| Address1: | 8765 E BELL RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852601320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808356100 | ||||||||
| FaxNumber: | 4804614243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 36659 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 223841 | 05 | AZ | MEDICAID |