Provider Demographics
NPI:1326118977
Name:LEE, DAE YONG (MD)
Entity Type:Individual
Prefix:
First Name:DAE
Middle Name:YONG
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 1:605 S ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-3817
Mailing Address - Country:US
Mailing Address - Phone:626-284-1736
Mailing Address - Fax:626-310-8304
Practice Address - Street 1:880 S ATLANTIC BLVD
Practice Address - Street 2:STE G 10
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4700
Practice Address - Country:US
Practice Address - Phone:626-872-6261
Practice Address - Fax:626-872-1948
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31152207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A311520OtherBLUE SHIELD OF CALIFORNIA
CA00A311521Medicaid
CA00A311520Medicaid
CAW18933OtherGROUP MEDICARE
CA00A311520OtherBLUE SHIELD OF CALIFORNIA
A84174Medicare UPIN
CA00A311520Medicaid