Provider Demographics
NPI:1073046371
Name:LE, PHU (MD)
Entity type:Individual
Prefix:
First Name:PHU
Middle Name:
Last Name:LE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:393-439-2352
Mailing Address - Fax:239-343-4008
Practice Address - Street 1:12600 CREEKSIDE LN STE 2
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3353
Practice Address - Country:US
Practice Address - Phone:239-343-9235
Practice Address - Fax:239-343-4008
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1417672084N0400X
LA3379322084N0400X
FLME168737208M00000X, 2084N0400X
NH257092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC122612900Medicaid
FL122612900Medicaid