Provider Demographics
NPI:1033103346
Name:LEE, WON BO (MD)
Entity Type:Individual
Prefix:
First Name:WON
Middle Name:BO
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4220 W 3RD ST
Mailing Address - Street 2:#102
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-3450
Mailing Address - Country:US
Mailing Address - Phone:213-384-0199
Mailing Address - Fax:213-384-1013
Practice Address - Street 1:4220 W 3RD ST
Practice Address - Street 2:#102
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3450
Practice Address - Country:US
Practice Address - Phone:213-384-0199
Practice Address - Fax:213-384-1013
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA323792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA323790Medicaid
CAA32379Medicare PIN