Provider Demographics
NPI:1790728020
Name:LEE, TIMOTHY DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DAVID
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6305 COYLE AVENUE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0438
Practice Address - Country:US
Practice Address - Phone:916-961-6920
Practice Address - Fax:916-966-5063
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA814162085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A814160OtherMEDICAL
P00288684OtherRAILROAD MEDICARE
P00288684OtherRAILROAD MEDICARE
CA680220314OtherFEDERAL TIN
H81579Medicare UPIN
CA341996544OtherSPECIAL TIN