Provider Demographics
NPI:1790764108
Name:LEE, JOHN SUNGCHULL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SUNGCHULL
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 1:5 BON AIR ROAD, STE. 105
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939
Mailing Address - Country:US
Mailing Address - Phone:415-461-0440
Mailing Address - Fax:415-461-3792
Practice Address - Street 1:5 BON AIR ROAD, STE. 105
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939
Practice Address - Country:US
Practice Address - Phone:415-461-0440
Practice Address - Fax:415-461-3792
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72201208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29435ZMedicare ID - Type Unspecified