Provider Demographics
NPI:1881072338
Name:MAHAJAN, AUDREY HAN NGOC LE (MD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:HAN NGOC LE
Last Name:MAHAJAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AUDREY
Other - Middle Name:LE
Other - Last Name:MAHAJAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4741
Mailing Address - Fax:401-444-4445
Practice Address - Street 1:3400 SPRUCE ST STE E
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4223
Practice Address - Country:US
Practice Address - Phone:267-847-9559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD471772207RI0200X
PAMT216168207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty