Provider Demographics
NPI:1376550715
Name:LEE, JAESUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:JAESUNG
Middle Name:
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 1:2876 SYCAMORE DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1530
Mailing Address - Country:US
Mailing Address - Phone:805-527-7320
Mailing Address - Fax:805-527-2426
Practice Address - Street 1:301 S MOORPARK RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1008
Practice Address - Country:US
Practice Address - Phone:805-379-9646
Practice Address - Fax:805-379-0611
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64716207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00957561OtherMEDICARE RAILROAD
CAG64716OtherLICENSE
CAG64716OtherLICENSE
CAF36189Medicare UPIN
CAG64716AMedicare PIN
CAP00957561OtherMEDICARE RAILROAD
CAG64716Medicare PIN