Provider Demographics
NPI:1174822639
Name:LEE, ELLEN EUN-OK (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:EUN-OK
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 1:9500 GILMAN DR
Mailing Address - Street 2:9116A
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-1023
Mailing Address - Country:US
Mailing Address - Phone:858-534-4040
Mailing Address - Fax:858-822-0231
Practice Address - Street 1:9500 GILMAN DR
Practice Address - Street 2:9116A
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-1023
Practice Address - Country:US
Practice Address - Phone:858-534-4040
Practice Address - Fax:858-822-0231
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1343112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program