Basic Information
| Provider Information | |||||||||
| NPI: | 1306372834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 W 39TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944034364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505732222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 375 89TH ST | ||||||||
| Address2: | |||||||||
| City: | DALY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940151802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503018650 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2017 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | A158112 | CA | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.