Provider Demographics
NPI:1871575092
Name:LE, PHUONG (OD)
Entity type:Individual
Prefix:
First Name:PHUONG
Middle Name:
Last Name:LE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:PHUONG-Y
Other - Middle Name:M
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1025 NW COUCH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-4131
Mailing Address - Country:US
Mailing Address - Phone:503-544-7046
Mailing Address - Fax:
Practice Address - Street 1:1040 NW 22ND AVE
Practice Address - Street 2:SUITE 168
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3057
Practice Address - Country:US
Practice Address - Phone:503-413-7022
Practice Address - Fax:503-413-7006
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2788 AT152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management