Provider Demographics
NPI:1922095256
Name:LEE, DAMON (MD)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:
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 3556
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-0556
Mailing Address - Country:US
Mailing Address - Phone:650-756-0110
Mailing Address - Fax:650-756-4475
Practice Address - Street 1:1800 SULLIVAN AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2228
Practice Address - Country:US
Practice Address - Phone:650-756-0110
Practice Address - Fax:650-756-4475
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA357050207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A357050Medicaid
CA00A357050Medicare ID - Type Unspecified
CA00A357050Medicaid