Provider Demographics
NPI:1487635298
Name:LEE, CHARLES KYUNG CHUL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KYUNG CHUL
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:K
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1545 PINE ST.
Mailing Address - Street 2:UNIT 101
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-4682
Mailing Address - Country:US
Mailing Address - Phone:415-933-8330
Mailing Address - Fax:415-933-8292
Practice Address - Street 1:1545 PINE ST.
Practice Address - Street 2:UNIT 101
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-1078
Practice Address - Country:US
Practice Address - Phone:415-933-8330
Practice Address - Fax:415-933-8292
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA829182086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A829180Medicaid
CA00A829180OtherBLUE SHIELD
CA00A829180OtherBLUE SHIELD
H98226Medicare UPIN