Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | A36130 | CA |
NPI | 1689622540 |
---|---|
Provider Name | Kyung Joon Lee |
First Address | Garden Grove, CA 92843-1901 |
Second Address | Garden Grove, CA 92843-1901 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2006 |
Last Update Date | 19/01/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C35455 | (02) | CA |