Healthcare Provider Details

I. General information

NPI: 1447411525
Provider Name (Legal Business Name): BAOQUANG S LE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 S MARIETTA PKWY SE
MARIETTA GA
30060-2748
US

IV. Provider business mailing address

PO BOX 740015
ATLANTA GA
30374-0015
US

V. Phone/Fax

Practice location:
  • Phone: 470-377-7228
  • Fax: 470-467-7583
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number104701
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDO1459
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS15776
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: