Provider Demographics
NPI:1750466728
Name:LEE, BOO W (MD)
Entity Type:Individual
Prefix:
First Name:BOO
Middle Name:W
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 FOREST AVENUE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128
Mailing Address - Country:US
Mailing Address - Phone:408-977-1310
Mailing Address - Fax:408-977-0140
Practice Address - Street 1:2040 FOREST AVENUE
Practice Address - Street 2:SUITE #3
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128
Practice Address - Country:US
Practice Address - Phone:408-977-1310
Practice Address - Fax:408-977-0140
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA383P3207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A383930Medicaid
CA00A383930Medicaid
A383930Medicare ID - Type Unspecified