Healthcare Provider Details

I. General information

NPI: 1629135389
Provider Name (Legal Business Name): MI LE TRAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11110 N TATUM BLVD SUITE 103
PHOENIX AZ
85028-1607
US

IV. Provider business mailing address

11110 N TATUM BLVD SUITE 103
PHOENIX AZ
85028-1607
US

V. Phone/Fax

Practice location:
  • Phone: 602-443-0400
  • Fax: 602-443-0401
Mailing address:
  • Phone: 602-443-0400
  • Fax: 602-443-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number22239
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: