Provider Demographics
NPI:1780694356
Name:LEE, SANG DAE (DPM)
Entity type:Individual
Prefix:DR
First Name:SANG
Middle Name:DAE
Last Name:LEE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 REDTAIL DR
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92823-1040
Mailing Address - Country:US
Mailing Address - Phone:909-882-3800
Mailing Address - Fax:
Practice Address - Street 1:2095 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4834
Practice Address - Country:US
Practice Address - Phone:909-882-3800
Practice Address - Fax:909-882-3380
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4416213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0253335Medicaid
CA000E44161Medicaid
CAP00147789OtherRAILROAD
CA000E44161Medicaid