Basic Information
| Provider Information | |||||||||
| NPI: | 1639190028 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | ROLAND | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | VA MED CENTER/UCSD RADIOLOGY # MC114 | ||||||||
| Address2: | 3350 LA JOLLA VILLAGE DRIVE | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | 8585527565 | ||||||||
| Practice Location | |||||||||
| Address1: | VA MED CENTER/UCSD RADIOLOGY # MC114 | ||||||||
| Address2: | 3350 LA JOLLA VILLAGE DRIVE | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | 8585527565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G57800 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | G57800 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 00G578000 | 05 | CA | MEDICAID |