Provider Demographics
NPI:1053308197
Name:LEE, CALVIN M (MD)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:M
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 578958
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-8958
Mailing Address - Country:US
Mailing Address - Phone:209-551-1888
Mailing Address - Fax:209-551-5662
Practice Address - Street 1:2336 SYLVAN AVE
Practice Address - Street 2:STE C
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-9294
Practice Address - Country:US
Practice Address - Phone:209-551-1888
Practice Address - Fax:209-551-5662
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82159208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A821590Medicaid
CABL8221234OtherDEA
CABL8221234OtherDEA
CA00A821590Medicaid