Provider Demographics
NPI:1508853896
Name:LEE, CRYSTINE M (MD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTINE
Middle Name:M
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 EAGLE GAP RD
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6672
Mailing Address - Country:US
Mailing Address - Phone:486-644-1057
Mailing Address - Fax:707-934-8107
Practice Address - Street 1:1055 BROADWAY STE A
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-7467
Practice Address - Country:US
Practice Address - Phone:866-441-0570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-01
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65187208600000X
CA065187208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABV932YMedicare PIN
CA00A651870Medicare PIN
CAI22074Medicare UPIN
CA122074Medicare UPIN