Provider Demographics
NPI:1548363492
Name:LEE, JONG IN (MD)
Entity type:Individual
Prefix:DR
First Name:JONG
Middle Name:IN
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 1:5471 LA PALMA AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1733
Mailing Address - Country:US
Mailing Address - Phone:714-521-6690
Mailing Address - Fax:714-521-9367
Practice Address - Street 1:5471 LA PALMA AVE STE 205
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1733
Practice Address - Country:US
Practice Address - Phone:714-521-6690
Practice Address - Fax:714-521-9367
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37705208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A377050Medicaid