Provider Demographics
NPI:1124343561
Name:LE, CUC KIM T (OD)
Entity type:Individual
Prefix:DR
First Name:CUC KIM
Middle Name:T
Last Name:LE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9529 S KILDARE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3222
Mailing Address - Country:US
Mailing Address - Phone:708-717-9523
Mailing Address - Fax:
Practice Address - Street 1:5959 LONG PRAIRIE ROAD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028
Practice Address - Country:US
Practice Address - Phone:214-513-8039
Practice Address - Fax:972-874-6719
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010315152W00000X
TX7923T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL579250097OtherMEDICARE PTAN
IL579270084OtherMEDICARE PTAN