Provider Demographics
NPI:1891890570
Name:LEE, JIN Y (MD)
Entity Type:Individual
Prefix:MR
First Name:JIN
Middle Name:Y
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 1:100 OCONNOR DR
Mailing Address - Street 2:#12
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128
Mailing Address - Country:US
Mailing Address - Phone:408-280-5655
Mailing Address - Fax:408-280-5631
Practice Address - Street 1:100 OCONNOR DR
Practice Address - Street 2:#12
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128
Practice Address - Country:US
Practice Address - Phone:408-280-5655
Practice Address - Fax:408-280-5631
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42438208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A424380Medicaid
A29583Medicare UPIN
00A424380Medicare ID - Type Unspecified