Provider Demographics
NPI: | 1164684973 |
---|---|
Name: | LEE, MIMI SHISHOU (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MIMI |
Middle Name: | SHISHOU |
Last Name: | LEE |
Suffix: | |
Gender: | F |
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: | 17360 BROOKHURST STREET |
Mailing Address - Street 2: | |
Mailing Address - City: | FOUNTAIN VALLEY |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92708-3720 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 877-844-0012 |
Mailing Address - Fax: | 714-665-4680 |
Practice Address - Street 1: | 17360 BROOKHURST STREET |
Practice Address - Street 2: | |
Practice Address - City: | FOUNTAIN VALLEY |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92708-3720 |
Practice Address - Country: | US |
Practice Address - Phone: | 877-844-0012 |
Practice Address - Fax: | 714-665-4680 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-07-02 |
Last Update Date: | 2024-02-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | A130577 | 2084N0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 1164684973 | Other | NPI |
CA | 1164684973 | Medicare UPIN | |
CA | 1164684973 | Medicare NSC | |
CA | 1164684973 | Medicare Oscar/Certification | |
CA | 1164684973 | Medicare PIN |