Provider Demographics
NPI:1568481471
Name:LEE, MI-JEONG
Entity Type:Individual
Prefix:DR
First Name:MI-JEONG
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MIJEONG
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2675 W OLYMPIC BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2880
Mailing Address - Country:US
Mailing Address - Phone:213-252-0036
Mailing Address - Fax:213-252-0043
Practice Address - Street 1:2675 W OLYMPIC BLVD
Practice Address - Street 2:STE 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2880
Practice Address - Country:US
Practice Address - Phone:213-252-0036
Practice Address - Fax:213-252-0043
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73179208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A731790Medicaid
H81124Medicare UPIN