Provider Demographics
NPI:1386749281
Name:LE THANH, CLEMENT PHUONG NGUYEN
Entity type:Individual
Prefix:
First Name:CLEMENT
Middle Name:PHUONG NGUYEN
Last Name:LE THANH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CLEMENT
Other - Middle Name:THANH
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 960
Mailing Address - Street 2:400 WARREN AVE STE 300
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337
Mailing Address - Country:US
Mailing Address - Phone:360-475-3709
Mailing Address - Fax:360-373-2096
Practice Address - Street 1:320 S KITSAP BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366
Practice Address - Country:US
Practice Address - Phone:360-876-7215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046845208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8465742Medicaid
WA8465742Medicaid