Provider Demographics
NPI:1518963321
Name:LEE, JAY KYUNG (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:KYUNG
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 1:12980 FREDERICK ST
Mailing Address - Street 2:STE A
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5263
Mailing Address - Country:US
Mailing Address - Phone:951-924-0108
Mailing Address - Fax:951-924-4776
Practice Address - Street 1:12980 FREDERICK ST
Practice Address - Street 2:STE A
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5263
Practice Address - Country:US
Practice Address - Phone:951-924-0108
Practice Address - Fax:951-924-4776
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85767174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist