Provider Demographics
NPI:1417047440
Name:LEE, KANG W (MD)
Entity Type:Individual
Prefix:
First Name:KANG
Middle Name:W
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 1277
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90609-1277
Mailing Address - Country:US
Mailing Address - Phone:562-906-6470
Mailing Address - Fax:562-946-9465
Practice Address - Street 1:12291 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-2500
Practice Address - Country:US
Practice Address - Phone:562-789-7712
Practice Address - Fax:562-789-7719
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32376174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA32376DMedicare PIN
CAA26785Medicare UPIN