Provider Demographics
NPI:1629081997
Name:JAIME S. LEE HO MD INC.
Entity Type:Organization
Organization Name:JAIME S. LEE HO MD INC.
Other - Org Name:MT MESA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE HO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-379-2426
Mailing Address - Street 1:PO BOX 1898
Mailing Address - Street 2:4308 BIRCH STREET
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240-1898
Mailing Address - Country:US
Mailing Address - Phone:760-379-2426
Mailing Address - Fax:760-379-2664
Practice Address - Street 1:4308 BIRCH STREET
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240
Practice Address - Country:US
Practice Address - Phone:760-379-2426
Practice Address - Fax:760-379-2664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43717207R00000X
CAA24547208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0022310Medicaid
CAZZZ98213ZMedicare PIN