Provider Demographics
NPI:1215023395
Name:LEE, MYRON (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRON
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3000 COLBY ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2058
Mailing Address - Country:US
Mailing Address - Phone:510-843-4613
Mailing Address - Fax:510-843-4652
Practice Address - Street 1:3000 COLBY ST
Practice Address - Street 2:SUITE 104
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2058
Practice Address - Country:US
Practice Address - Phone:510-843-4613
Practice Address - Fax:510-843-4652
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA00A222740207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A222740Medicaid
CAA22999Medicare UPIN
CA00A222740Medicaid