Provider Demographics
NPI:1295744852
Name:DAE YONG LEE M.D. A MEDICAL CORPORATION
Entity type:Organization
Organization Name:DAE YONG LEE M.D. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAE
Authorized Official - Middle Name:YONG
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-433-0246
Mailing Address - Street 1:101 S 1ST ST
Mailing Address - Street 2:1000
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1938
Mailing Address - Country:US
Mailing Address - Phone:818-845-6206
Mailing Address - Fax:818-845-9774
Practice Address - Street 1:2131 W 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1901
Practice Address - Country:US
Practice Address - Phone:213-484-5525
Practice Address - Fax:213-413-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A331520OtherBLUE SHIELD
CA00A311520Medicaid
CA00A311520Medicaid