Basic Information
Provider Information | |||||||||
NPI: | 1316982150 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEE | ||||||||
FirstName: | GI-HYUNG | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEE | ||||||||
OtherFirstName: | MARTHA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 635 | ||||||||
Address2: |   | ||||||||
City: | WEST COVINA | ||||||||
State: | CA | ||||||||
PostalCode: | 917930635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6268139988 | ||||||||
FaxNumber: | 6268130075 | ||||||||
Practice Location | |||||||||
Address1: | 1115 S SUNSET AVE | ||||||||
Address2: |   | ||||||||
City: | WEST COVINA | ||||||||
State: | CA | ||||||||
PostalCode: | 917903940 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6268139988 | ||||||||
FaxNumber: | 6268130075 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2006 | ||||||||
LastUpdateDate: | 10/01/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G72584 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 00G725840 | 01 | CA | BCBS | OTHER | 00G725840 | 05 | CA |   | MEDICAID | P00617444 | 01 | CA | RR MEDICARE | OTHER | WG72584 | 01 | CA | MEDICARE PTAN | OTHER |