Provider Demographics
NPI:1578911376
Name:LEI, JIBONG (DPM)
Entity Type:Individual
Prefix:
First Name:JIBONG
Middle Name:
Last Name:LEI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 ORANGE TREE LN STE 200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4587
Mailing Address - Country:US
Mailing Address - Phone:909-557-1600
Mailing Address - Fax:909-557-1732
Practice Address - Street 1:1901 W LUGONIA AVE STE 120
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-9704
Practice Address - Country:US
Practice Address - Phone:909-557-1600
Practice Address - Fax:909-557-1732
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5523213ES0103X
OH59.000622390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program