Provider Demographics
NPI:1205913969
Name:LEE, RAY W (MD)
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:W
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 1:17055 GRANDEE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2125
Mailing Address - Country:US
Mailing Address - Phone:703-282-0236
Mailing Address - Fax:
Practice Address - Street 1:600 MARINE BLVD
Practice Address - Street 2:
Practice Address - City:MOSS BEACH
Practice Address - State:CA
Practice Address - Zip Code:94038-9641
Practice Address - Country:US
Practice Address - Phone:650-563-7107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232526207P00000X
CAG66832207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA930123436OtherRRMCR
VA5878501Medicaid
VAE85812Medicare UPIN