Provider Demographics
NPI:1619243086
Name:LEE, ELAINE (MD)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 COUNTRY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-7319
Mailing Address - Country:US
Mailing Address - Phone:925-435-4355
Mailing Address - Fax:925-978-0991
Practice Address - Street 1:1480 64TH ST STE 100
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2038
Practice Address - Country:US
Practice Address - Phone:510-629-6682
Practice Address - Fax:510-830-3316
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA128258208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program