Provider Demographics
NPI:1740373356
Name:LEE, GERRY M (MD)
Entity type:Individual
Prefix:
First Name:GERRY
Middle Name:M
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 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:ST 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:3133 PROFESSIONAL DRIVE
Practice Address - Street 2:#20
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603
Practice Address - Country:US
Practice Address - Phone:530-885-8821
Practice Address - Fax:530-885-6554
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG40717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G407170Medicaid
00G407170Medicare ID - Type Unspecified
A48329Medicare UPIN