Provider Demographics
NPI:1326009572
Name:LEE, GORDON K (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:K
Last Name: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 1:770 WELCH ROAD
Mailing Address - Street 2:SUITE 400 MAILCODE 5715
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-5715
Mailing Address - Country:US
Mailing Address - Phone:650-723-5824
Mailing Address - Fax:650-725-6605
Practice Address - Street 1:770 WELCH RD
Practice Address - Street 2:SUITE 400, MAILCODE 5715
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1511
Practice Address - Country:US
Practice Address - Phone:650-723-5824
Practice Address - Fax:650-725-6605
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA683222086S0122X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151752-03OtherCSHCN
TXP00166123OtherRR/MEDICARE
TX1591752-03Medicaid
TX8M7997OtherBLUE SHIELD
TXP00166123OtherRR/MEDICARE
TX1591752-03Medicaid