Provider Demographics
NPI:1114910239
Name:LEE, JOHN H (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
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 1:2040 E MARIPOSA AVE
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-5027
Mailing Address - Country:US
Mailing Address - Phone:213-266-5600
Mailing Address - Fax:
Practice Address - Street 1:2040 E MARIPOSA AVE
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245
Practice Address - Country:US
Practice Address - Phone:213-266-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7195207Y00000X
IA31332207Y00000X
NDPT 13015207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18279Medicaid
IA44545OtherWELLMARK BCBS
IA6140715Medicaid
G33266Medicare UPIN
IA6140715Medicaid
ND18279Medicaid
IAI5684Medicare PIN
NDN719312Medicare PIN