Provider Demographics
NPI:1164473351
Name:KISSEL, LEE (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:KISSEL
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 1:3105 LOMITA BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5108
Mailing Address - Country:US
Mailing Address - Phone:310-784-4926
Mailing Address - Fax:310-891-6793
Practice Address - Street 1:855 MANHATTAN BEACH BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-4965
Practice Address - Country:US
Practice Address - Phone:310-939-7858
Practice Address - Fax:310-939-7842
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G456420OtherBLUE SHIELD
CAWG45642CMedicare UPIN
A50128Medicare UPIN