Provider Demographics
NPI:1942349378
Name:LEE, JAE YONG (MD)
Entity Type:Individual
Prefix:
First Name:JAE YONG
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 1:10917 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3044
Mailing Address - Country:US
Mailing Address - Phone:203-482-7557
Mailing Address - Fax:
Practice Address - Street 1:4791 E PALM CANYON DR STE 100
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-5232
Practice Address - Country:US
Practice Address - Phone:760-834-7930
Practice Address - Fax:760-834-7931
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC150254207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000112201Medicare PIN
MA2143895Medicaid