Provider Demographics
NPI:1689618464
Name:LEE, JOHN (MD, MPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3005
Mailing Address - Country:US
Mailing Address - Phone:626-449-7000
Mailing Address - Fax:818-301-7443
Practice Address - Street 1:4358 CHEVY CHASE DR STE 300
Practice Address - Street 2:
Practice Address - City:LA CANADA FLINTRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91011-3203
Practice Address - Country:US
Practice Address - Phone:626-449-7000
Practice Address - Fax:818-301-7443
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA066604207P00000X
CAA066042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165302406Medicaid
TXH47396Medicare UPIN
TX8D5717Medicare ID - Type Unspecified
CADN425ZMedicare PIN