Provider Demographics
NPI:1477014868
Name:BRUCE B LEE, M.D.
Entity Type:Organization
Organization Name:BRUCE B LEE, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-660-6030
Mailing Address - Street 1:PO BOX 940358
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93094-0358
Mailing Address - Country:US
Mailing Address - Phone:800-660-6030
Mailing Address - Fax:310-564-0316
Practice Address - Street 1:1617 WESTCLIFF DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5524
Practice Address - Country:US
Practice Address - Phone:800-660-6030
Practice Address - Fax:310-564-0316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG490850OtherANTHEM