Provider Demographics
NPI:1952394553
Name:LEE, SOON T (MD)
Entity Type:Individual
Prefix:
First Name:SOON
Middle Name:T
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:S
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3300 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3028
Mailing Address - Country:US
Mailing Address - Phone:510-444-1600
Mailing Address - Fax:510-444-5117
Practice Address - Street 1:3300 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3028
Practice Address - Country:US
Practice Address - Phone:510-444-1600
Practice Address - Fax:510-444-5117
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA443122207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A443120Medicaid
CA00A443120Medicaid
F20856Medicare UPIN