Provider Demographics
NPI:1275532145
Name:LEE, SIMON KWANMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:KWANMIN
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1828 EL CAMINO REAL
Mailing Address - Street 2:SUITE 406
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3103
Mailing Address - Country:US
Mailing Address - Phone:650-692-1388
Mailing Address - Fax:650-692-1380
Practice Address - Street 1:1828 EL CAMINO REAL
Practice Address - Street 2:SUITE 406
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3103
Practice Address - Country:US
Practice Address - Phone:650-692-1388
Practice Address - Fax:650-692-1380
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G831691Medicaid
CAG34878Medicare UPIN
CA00G831691Medicaid
CA00G831691Medicare ID - Type Unspecified