Provider Demographics
NPI:1295716884
Name:LE, THU VAN (MD)
Entity type:Individual
Prefix:
First Name:THU
Middle Name:VAN
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 1:1212 S 11TH ST
Mailing Address - Street 2:SUITE 39
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4021
Mailing Address - Country:US
Mailing Address - Phone:253-627-6128
Mailing Address - Fax:
Practice Address - Street 1:1212 S 11TH ST
Practice Address - Street 2:SUITE 39
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4021
Practice Address - Country:US
Practice Address - Phone:253-627-6128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021181208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8480097Medicaid
WA1314608Medicaid
WAG8863521Medicare ID - Type Unspecified
WA8480097Medicaid
WA1314608Medicaid
WAG8804755Medicare PIN