Provider Demographics
NPI:1629034558
Name:PU, LEE L Q (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:L Q
Last Name:PU
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 STOCKTON BLVD., FIRST FLOOR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817
Mailing Address - Country:US
Mailing Address - Phone:916-734-2130
Mailing Address - Fax:916-734-7104
Practice Address - Street 1:2221 STOCKTON BLVD., FIRST FLOOR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817
Practice Address - Country:US
Practice Address - Phone:916-734-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55357208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64016108Medicaid
KY64016108Medicaid
H24958Medicare UPIN