=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225232051
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH ANN LE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2007
-----------------------------------------------------
Last Update Date | 03/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 N CLYDE MORRIS BLVD
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-2733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-238-3221
-----------------------------------------------------
Fax | 386-238-3235
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 N CLYDE MORRIS BLVD
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-2733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-676-7130
-----------------------------------------------------
Fax | 862-383-3235
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | FL99663
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------