Provider Demographics
NPI:1073633467
Name:LEE, GARY CHEUKMAN (MD , PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:CHEUKMAN
Last Name:LEE
Suffix:
Gender:M
Credentials:MD , PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4980 BARRANCA PKWY STE 202
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-8653
Mailing Address - Country:US
Mailing Address - Phone:949-733-1336
Mailing Address - Fax:949-733-3387
Practice Address - Street 1:4980 BARRANCA PKWY STE 202
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-8653
Practice Address - Country:US
Practice Address - Phone:949-733-1336
Practice Address - Fax:949-733-3387
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA055074207NS0135X, 207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG73961Medicare UPIN
CAW16352Medicare ID - Type UnspecifiedPROVIDER NUMBER