Provider Demographics
NPI:1457468514
Name:LEE, SALLY (MD, DO)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MD, DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5965 SEVERIN DR.
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3428
Mailing Address - Country:US
Mailing Address - Phone:619-583-4295
Mailing Address - Fax:619-825-7300
Practice Address - Street 1:5965 SEVERIN DR.
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3428
Practice Address - Country:US
Practice Address - Phone:619-583-4295
Practice Address - Fax:619-825-7300
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A80880207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX8088Medicaid
CA1285859900OtherNPI BUSINESS
CA00AX80880Medicaid