Basic Information
Provider Information | |||||||||
NPI: | 1578911376 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEI | ||||||||
FirstName: | JIBONG | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1801 ORANGE TREE LN STE 200 | ||||||||
Address2: |   | ||||||||
City: | REDLANDS | ||||||||
State: | CA | ||||||||
PostalCode: | 923744587 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095571600 | ||||||||
FaxNumber: | 9095571732 | ||||||||
Practice Location | |||||||||
Address1: | 1901 W LUGONIA AVE STE 120 | ||||||||
Address2: |   | ||||||||
City: | REDLANDS | ||||||||
State: | CA | ||||||||
PostalCode: | 923749704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095571600 | ||||||||
FaxNumber: | 9095571732 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2016 | ||||||||
LastUpdateDate: | 07/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | E5523 | CA | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.