Provider Demographics
NPI:1720075641
Name:LEE, ERIC W (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
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 1:1310 W STEWART DR
Mailing Address - Street 2:SUITE 510
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3854
Mailing Address - Country:US
Mailing Address - Phone:714-538-8549
Mailing Address - Fax:714-538-1547
Practice Address - Street 1:1310 W STEWART DR
Practice Address - Street 2:SUITE 510
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3854
Practice Address - Country:US
Practice Address - Phone:714-538-8549
Practice Address - Fax:714-538-1547
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65673174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0003520Medicaid
CAH57567Medicare UPIN
CAWA65673AMedicare ID - Type Unspecified