Healthcare Provider Details

I. General information

NPI: 1932064755
Provider Name (Legal Business Name): ETHAN MEE LE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2025
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 TELEGRAPH AVE # 9
BERKELEY CA
94705-1984
US

IV. Provider business mailing address

3101 TELEGRAPH AVE # 9
BERKELEY CA
94705-1984
US

V. Phone/Fax

Practice location:
  • Phone: 510-812-7084
  • Fax:
Mailing address:
  • Phone: 510-812-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberL10055
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: