Provider Demographics
NPI:1790830156
Name:LEE, LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
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 1:150 S RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-3166
Mailing Address - Country:US
Mailing Address - Phone:626-300-0008
Mailing Address - Fax:
Practice Address - Street 1:150 S RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-3166
Practice Address - Country:US
Practice Address - Phone:626-300-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61152207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A611520Medicaid
CA00A611520Medicaid
WA61152BMedicare PIN
CAG72719Medicare UPIN