Provider Demographics
NPI:1942304373
Name:LEE, THOMAS T, (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:T,
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4950 SAN BERNARDINO ST
Mailing Address - Street 2:STE #106
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2328
Mailing Address - Country:US
Mailing Address - Phone:909-450-5000
Mailing Address - Fax:909-621-6735
Practice Address - Street 1:4950 SAN BERNARDINO ST
Practice Address - Street 2:STE #106
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2328
Practice Address - Country:US
Practice Address - Phone:909-450-5000
Practice Address - Fax:909-621-6735
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37294207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0051992Medicaid
CAGR0051991Medicaid
CAGR0051990Medicaid
CAA88411Medicare UPIN
CAA88411Medicare UPIN