Provider Demographics
NPI:1417023227
Name:LEE, KENNETH WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
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 1:160 E ARTESIA ST
Mailing Address - Street 2:140
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2900
Mailing Address - Country:US
Mailing Address - Phone:909-622-3800
Mailing Address - Fax:909-622-2600
Practice Address - Street 1:160 E ARTESIA ST
Practice Address - Street 2:140
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2900
Practice Address - Country:US
Practice Address - Phone:909-622-3800
Practice Address - Fax:909-622-2600
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79488207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A694880Medicaid
I34982Medicare UPIN
CA00A694880Medicaid