Provider Demographics
NPI:1083656193
Name:LEE, THEODORE J (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:J
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:484 PANORAMIC HWY
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-5065
Mailing Address - Country:US
Mailing Address - Phone:415-888-3193
Mailing Address - Fax:
Practice Address - Street 1:505 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2204
Practice Address - Country:US
Practice Address - Phone:415-353-1374
Practice Address - Fax:415-353-8594
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA737222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A737220Medicaid
CA00A737220Medicaid
CAI31290Medicare UPIN