Provider Demographics
NPI:1912935388
Name:LEE, KRISTINA KANG (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:KANG
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EUNI
Other - Middle Name:KRISTINA
Other - Last Name:KANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2620 E LAS POSAS ROAD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010
Mailing Address - Country:US
Mailing Address - Phone:805-383-2100
Mailing Address - Fax:805-445-9247
Practice Address - Street 1:2620 E LAS POSAS ROAD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010
Practice Address - Country:US
Practice Address - Phone:805-383-2100
Practice Address - Fax:805-445-9247
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79226208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG13168Medicare UPIN