Provider Demographics
NPI:1447303896
Name:LE, KHANHTRANG (OD)
Entity type:Individual
Prefix:DR
First Name:KHANHTRANG
Middle Name:
Last Name:LE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KT
Other - Middle Name:
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:16505 SIERRA LAKES PARKWAY
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336
Mailing Address - Country:US
Mailing Address - Phone:909-770-5652
Mailing Address - Fax:909-770-5651
Practice Address - Street 1:16505 SIERRA LAKES PARKWAY
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336
Practice Address - Country:US
Practice Address - Phone:909-770-5652
Practice Address - Fax:909-770-5651
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP10259T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU58760Medicare UPIN