Provider Demographics
NPI:1609072503
Name:JAESUNG LEE
Entity Type:Organization
Organization Name:JAESUNG LEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAESUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-379-9646
Mailing Address - Street 1:301 S MOORPARK RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1008
Mailing Address - Country:US
Mailing Address - Phone:805-379-9646
Mailing Address - Fax:805-379-0611
Practice Address - Street 1:301 S MOORPARK RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1008
Practice Address - Country:US
Practice Address - Phone:805-379-9646
Practice Address - Fax:805-379-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64716174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG64716OtherLICENSE
CAF36189Medicare UPIN
CAG64716Medicare PIN
CAG64716OtherLICENSE
CAG64716AMedicare PIN