Provider Demographics
NPI:1518011287
Name:LE, CAROL (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:LE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 RIVERPLACE BLVD
Mailing Address - Street 2:SUITE 620
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-9046
Mailing Address - Country:US
Mailing Address - Phone:904-396-6620
Mailing Address - Fax:904-396-6528
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1309
Practice Address - Country:US
Practice Address - Phone:208-367-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0066950207R00000X, 208M00000X
IDM-17368207R00000X
FLME105966207R00000X
LA34222208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA579975643AMedicaid
FL0026292-00Medicaid
FLP00855547OtherRR MEDICARE
FLP00855547OtherRR MEDICARE