Provider Demographics
NPI:1013056498
Name:LEE, JOHNSON
Entity Type:Individual
Prefix:
First Name:JOHNSON
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1637 STROBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5101
Mailing Address - Country:US
Mailing Address - Phone:510-538-5328
Mailing Address - Fax:
Practice Address - Street 1:1637 STROBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5101
Practice Address - Country:US
Practice Address - Phone:510-538-5328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5613171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC 5613OtherACUPUNCTURIST