Provider Demographics
NPI:1508863499
Name:LEE, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
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 1:16101 ROCKYRIVER LN
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-1933
Mailing Address - Country:US
Mailing Address - Phone:562-404-5574
Mailing Address - Fax:
Practice Address - Street 1:1665 SCENIC AVE
Practice Address - Street 2:100
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-1445
Practice Address - Country:US
Practice Address - Phone:714-436-4700
Practice Address - Fax:714-436-4801
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75527207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A755270OtherMEDI CAL
CAH69921Medicare UPIN