Provider Demographics
NPI:1912105297
Name:LEE, JAE HOON (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:HOON
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 1:5016 CHESEBRO RD
Mailing Address - Street 2:STE 200
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-2210
Mailing Address - Country:US
Mailing Address - Phone:818-528-6164
Mailing Address - Fax:818-991-1200
Practice Address - Street 1:520 N MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4623
Practice Address - Country:US
Practice Address - Phone:714-352-5800
Practice Address - Fax:714-352-5801
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA109172207QG0300X
NVLL1795390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA109172OtherLICENSE
NVLL1795OtherNV MEDICAL LIC