Provider Demographics
NPI:1366758849
Name:LE, KRISTY QUYNH (OD)
Entity type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:QUYNH
Last Name:LE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3287 BELMONT GLEN DR SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-9118
Mailing Address - Country:US
Mailing Address - Phone:954-224-3428
Mailing Address - Fax:
Practice Address - Street 1:3378 COBB PKWY NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-8358
Practice Address - Country:US
Practice Address - Phone:954-224-3428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2611152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I414641Medicare PIN