Provider Demographics
NPI:1972607364
Name:LEE, YONG TAI (MD)
Entity Type:Individual
Prefix:DR
First Name:YONG
Middle Name:TAI
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 1:903 CRENSHAW BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-1967
Mailing Address - Country:US
Mailing Address - Phone:323-731-0681
Mailing Address - Fax:323-731-0832
Practice Address - Street 1:903 CRENSHAW BLVD STE 302
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-1967
Practice Address - Country:US
Practice Address - Phone:323-731-0681
Practice Address - Fax:323-731-0832
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67974207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1972607364OtherNPI
CA00G679740Medicaid
CA1972607364OtherNPI
CAE38545Medicare UPIN
CADR414ZMedicare PIN