Provider Demographics
NPI:1942236674
Name:TAI KWONG LEE,MD,PHD, INC
Entity type:Organization
Organization Name:TAI KWONG LEE,MD,PHD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAI
Authorized Official - Middle Name:KWONG
Authorized Official - Last Name:LEE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:818-888-7815
Mailing Address - Street 1:PO BOX 7001
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-7001
Mailing Address - Country:US
Mailing Address - Phone:818-888-7815
Mailing Address - Fax:818-715-1722
Practice Address - Street 1:15107 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4542
Practice Address - Country:US
Practice Address - Phone:818-782-6600
Practice Address - Fax:818-715-1722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69722207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A697221OtherBLUE SHIELD
CAWA69722AOtherMEDICARE PPIN
CAWA69722AOtherMEDICARE PPIN
CAW18290Medicare PIN