Provider Demographics
NPI:1679899694
Name:LEE, JEDIAH JAEHEE (MD)
Entity Type:Individual
Prefix:
First Name:JEDIAH
Middle Name:JAEHEE
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JEDIAH
Other - Middle Name:JAEHEE
Other - Last Name:SIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:13652 CANTARA ST
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-5423
Mailing Address - Country:US
Mailing Address - Phone:818-375-2000
Mailing Address - Fax:
Practice Address - Street 1:13652 CANTARA ST
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-5423
Practice Address - Country:US
Practice Address - Phone:818-375-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269437-1207R00000X
CAA135858207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine