Provider Demographics
NPI:1023259819
Name:LEE, JONG D (MD)
Entity type:Individual
Prefix:
First Name:JONG
Middle Name:D
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:9828 GARDEN GROVE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1659
Mailing Address - Country:US
Mailing Address - Phone:714-530-9633
Mailing Address - Fax:714-530-4410
Practice Address - Street 1:9828 GARDEN GROVE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1659
Practice Address - Country:US
Practice Address - Phone:714-530-9633
Practice Address - Fax:714-530-4410
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAC39144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC39144OtherSTATE LICENSE