Provider Demographics
NPI:1790779106
Name:LEE, BONNIE J (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:J
Last Name:LEE
Suffix:
Gender:F
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:PO BOX 2106
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84091-2106
Mailing Address - Country:US
Mailing Address - Phone:801-557-4595
Mailing Address - Fax:801-596-8080
Practice Address - Street 1:554 S 800 E
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84102-2931
Practice Address - Country:US
Practice Address - Phone:801-557-4595
Practice Address - Fax:801-596-8080
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1711891205207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1790779106Medicaid
UTA52256Medicare UPIN
UT1790779106Medicaid