Basic Information
| Provider Information | |||||||||
| NPI: | 1023051174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | BENNETT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8510 BALBOA BLVD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913253583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183575048 | ||||||||
| FaxNumber: | 8186543417 | ||||||||
| Practice Location | |||||||||
| Address1: | 2755 ALAMO ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930651311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055226577 | ||||||||
| FaxNumber: | 8055227030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G64625 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BL1753448 | 01 | CA | DEA NUMBER | OTHER | 00G646250 | 05 | CA | MEDICAID |