MEDICARE: DR. MI LE TRAN 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	2084P0015X	Psychosomatic Medicine Physician	22239	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22239 MD	OTHER	AZ	STATE MEDICAL LICENSE

General Provider Information

NPI Number	:	1629135389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MI LE TRAN M.D.

Provider Business Mailing Address
First Line	:	11110 N TATUM BLVD
Second Line	:	SUITE 103
City	:	PHOENIX
State	:	AZ
Zip	:	85028-1607
Country	:	US
Telephone Number	:	602-443-0400
Fax Number	:	602-443-0401

Provider Business Practice Location Address
First Line	:	11110 N TATUM BLVD
Second Line	:	SUITE 103
City	:	PHOENIX
State	:	AZ
Zip	:	85028-1607
Country	:	US
Telephone Number	:	602-443-0400
Fax Number	:	602-443-0401

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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