Provider Demographics
NPI:1720226160
Name:LEE, KIMO GREG (SFIDC)
Entity Type:Individual
Prefix:MR
First Name:KIMO
Middle Name:GREG
Last Name:LEE
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:BLDG 601 MCCAIN BLVD
Mailing Address - Street 2:BRANCH MEDICAL CLINIC NAVAL BASE CORONADO
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92135-7046
Mailing Address - Country:US
Mailing Address - Phone:619-545-8229
Mailing Address - Fax:
Practice Address - Street 1:BLD 601 MCCAIN BLDG
Practice Address - Street 2:BRANCH MEDICAL CLINIC NAVAL BASE CORONADO
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92135-7046
Practice Address - Country:US
Practice Address - Phone:619-545-8229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman