Provider Demographics
NPI:1124070420
Name:LE, MIMI QUYEN THAI THUC (MD)
Entity type:Individual
Prefix:DR
First Name:MIMI
Middle Name:QUYEN THAI THUC
Last Name:LE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10800 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3043
Mailing Address - Country:US
Mailing Address - Phone:866-984-7483
Mailing Address - Fax:951-353-5073
Practice Address - Street 1:10800 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3043
Practice Address - Country:US
Practice Address - Phone:866-984-7483
Practice Address - Fax:951-353-5073
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88869207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A888690Medicaid
CAWA88869AMedicare ID - Type UnspecifiedALVARADO OFFICE
CAI35963Medicare UPIN
CA00A888690Medicaid