MEDICARE: DR. MARK BAO LE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	MD483643	PA
2	2085R0204X	Vascular & Interventional Radiology Physician	A160384	CA
3	2085R0202X	Diagnostic Radiology Physician	A160384	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487090213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK BAO LE M.D.

Provider Business Mailing Address
First Line	:	110 W LAS TUNAS DR STE C
Second Line	:
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-1346
Country	:	US
Telephone Number	:	626-653-8712
Fax Number	:

Provider Business Practice Location Address
First Line	:	7171 N DALE MABRY HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-2665
Country	:	US
Telephone Number	:	317-614-9804
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2013
Last Update Date	:	08/14/2025

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Directions to “ DR. MARK BAO LE M.D.” Practice Location

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