1407116106 NPI number — DAT TAT LE MD EFFECTIVE 6/1/12

Table of content: DAT TAT LE MD EFFECTIVE 6/1/12 (NPI 1407116106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407116106 NPI number — DAT TAT LE MD EFFECTIVE 6/1/12

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LE
Provider First Name:
DAT
Provider Middle Name:
TAT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD EFFECTIVE 6/1/12
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407116106
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 BURLINGTON AVE
Provider Second Line Business Mailing Address:
APT 2-302
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01887-3934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-940-4970
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 GENERAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01841-2961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-638-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 262627 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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