Provider Demographics
NPI:1487074530
Name:LE, KHANH KHIEM PHAN (MD)
Entity type:Individual
Prefix:
First Name:KHANH
Middle Name:KHIEM PHAN
Last Name:LE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6012 PLATH ST
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5971
Mailing Address - Country:US
Mailing Address - Phone:704-241-8182
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST # 555
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7199
Practice Address - Country:US
Practice Address - Phone:501-686-5785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-03268207RC0200X, 207R00000X, 207RP1001X
OK30679207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1487074530Medicaid