Provider Demographics
NPI:1861510760
Name:LEE, IRWIN H (MD)
Entity Type:Individual
Prefix:DR
First Name:IRWIN
Middle Name:H
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:PO BOX 756
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-0756
Mailing Address - Country:US
Mailing Address - Phone:209-543-0684
Mailing Address - Fax:209-343-3809
Practice Address - Street 1:301 PROFESSIONAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2152
Practice Address - Country:US
Practice Address - Phone:707-584-2200
Practice Address - Fax:707-584-7582
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010816652085R0001X, 390200000X
CAA1030382085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861510760Medicaid