Basic Information
Provider Information | |||||||||
NPI: | 1881613412 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEE | ||||||||
FirstName: | BYONG-WHA | ||||||||
MiddleName: | ESTHER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEE | ||||||||
OtherFirstName: | ESTHER | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9602 | ||||||||
Address2: |   | ||||||||
City: | MISSION HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 913469602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188375691 | ||||||||
FaxNumber: | 8187924793 | ||||||||
Practice Location | |||||||||
Address1: | 14550 SOLEDAD CANYON RD | ||||||||
Address2: |   | ||||||||
City: | CANYON COUNTRY | ||||||||
State: | CA | ||||||||
PostalCode: | 913872200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612505244 | ||||||||
FaxNumber: | 6612517308 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 07/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | G68100 | CA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00G681000 | 05 | CA |   | MEDICAID |