Provider Demographics
NPI:1487090213
Name:LE, MARK BAO (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:BAO
Last Name:LE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:110 W LAS TUNAS DR STE C
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1346
Mailing Address - Country:US
Mailing Address - Phone:626-653-8712
Mailing Address - Fax:
Practice Address - Street 1:7171 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2665
Practice Address - Country:US
Practice Address - Phone:317-614-9804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2022-12-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA1603842085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology