Provider Demographics
NPI:1265479745
Name:O-LEE, TSUNGJU (MD)
Entity Type:Individual
Prefix:
First Name:TSUNGJU
Middle Name:
Last Name:O-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 W CHARLESTON BLVD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2227
Mailing Address - Country:US
Mailing Address - Phone:702-671-2298
Mailing Address - Fax:702-384-7506
Practice Address - Street 1:11234 ANDERSON ST RM 2586
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-7884
Practice Address - Fax:909-558-4819
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77684207Y00000X
NV12715207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZP4310ZMedicare ID - Type Unspecified