Basic Information
| Provider Information | |||||||||
| NPI: | 1386905099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | NATHANIEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 SANTA MONICA BLVD | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104495291 | ||||||||
| FaxNumber: | 3105827185 | ||||||||
| Practice Location | |||||||||
| Address1: | 8936 SOUTHPOINTE DR STE B4 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462277506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176210668 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2012 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2086X0206X | 01086218A | IN | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 300052400 | 05 | IN | MEDICAID |