Provider Demographics
NPI:1376586990
Name:LEE, MARC (MD)
Entity Type:Individual
Prefix:
First Name:MARC
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:PO BOX 1628
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91507
Mailing Address - Country:US
Mailing Address - Phone:818-843-2835
Mailing Address - Fax:818-843-3310
Practice Address - Street 1:1624 W OLIVE AVE
Practice Address - Street 2:SUITE F
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-2459
Practice Address - Country:US
Practice Address - Phone:818-843-2835
Practice Address - Fax:818-843-3310
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA945662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A945660OtherMEDICAL
CAW094566AMedicare ID - Type UnspecifiedWESTWOOD
CA00A945660OtherMEDICAL
CAI55326Medicare UPIN