Provider Demographics
NPI:1184772972
Name:LEE, JIVIANNE KRISTINE TAN (MD)
Entity type:Individual
Prefix:
First Name:JIVIANNE
Middle Name:KRISTINE TAN
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1131 WILSHIRE BLVD STE 302
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2061
Practice Address - Country:US
Practice Address - Phone:424-259-6559
Practice Address - Fax:310-319-3877
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2019-12-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA72248207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck