Provider Demographics
NPI:1497834352
Name:LEE, GARY TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:TIMOTHY
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 5639
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-0639
Mailing Address - Country:US
Mailing Address - Phone:650-344-6353
Mailing Address - Fax:650-344-8661
Practice Address - Street 1:2140 CARLMONT DR
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-3417
Practice Address - Country:US
Practice Address - Phone:650-591-9601
Practice Address - Fax:888-480-8735
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74496207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F70246Medicare UPIN
00G744960Medicare PIN